^^K% 


Columbia  Win\\itriitv 
intf)E€itpofilcto»orb 

CoUcge  of  ^bpsiiciang  anb  ^urgcong 


Reference  Hibrarp 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practiceofpediatOOcarr 


LIST   OF  CONTRIBUTORS. 


ABT.   ISAAC  ARTHUR,   M.D. 
BOVAIRD,  DAVID,  Jr.,  M.D. 
CRANDALL.  FLOYD  M.,  M.D. 
DADE.  CHARLES  TOWNSHEND.   M.D. 
DAVIS.  EDV/ARD  P..  M.D. 
JENNINGS.  CHARLES  GODWIN.  M.D. 

MCCARTHY.  DANIEL  J..  M.D. 

NICOLL.  MATTHIAS,  Jr.,  M.D. 

POYNTON,  F.  JOHN,  M.D..  F.  R.  C.  P. 

RIVIERE,  CLIVE.   M.D  .  M.  R.  C.  P..  Etc. 

RUHRAH.    JOHN,  M.D. 

SOUTHWORTH.  THOMAS  S..  M.D. 

TUTTLE.  GEORGE   M.,  M.D. 

YALE.  LEROY  MILTON.  M.D. 


Zbc  practitioner's  Xibrarie 


THE 


PRACTICE  OF  PEDIATRICS 


m  ORIGINAL  CONTRIBUTIONS 


AMEEICAN  AND  ENGLISH  AUTHOES 


EDITED  BY 

WALTER  LESTER  CARR,  A.M.,  M.D. 

CONSULTING    PHYSICIAN   TO   THE   rREN9H    HOSPITAL,   NEW    YOKK;  TO    THE    NEW   YORK    EYE   AND   BAB 

INriRMARY;  VISITING    PHYSICIAN   TO   THE    NEW   YORK    CITY   CHILDREN'S    HOSPITALS 

AND   SCHOOLS   ;  MEMBER   OF   THE   AMERICAN   PEDIATRIC   SOCIETY; 

FORMERLY  EDITOR  OF  "ARCHIVES  OF  PEDIATRICS." 


ILLUSTRATED  WITH   199    ENGRAVINGS  AND  32   FULL-PAGE  PLATES 


LEA   BROTHERS   &  CO. 

PHILADELPHIA    AND    NEW  YORK 
1906 


Entorcd  accnnlinj:  to  tin'  Aci    f>l   Conpnss.  m  the  \<ar   19()H.  hy 

l.KA    JiK(>'JHP:RS    .t    CO.. 
in  the  Office  of  the  Libruriau  of  Congress.     All  rights  reserved. 


DOR  NAN,      PRINTER 
P  H  I  I.  A  n  K  I,  P  H  I  A 


PEEFACE. 


A  COMPREHENSIVE  and  authoritative  survey  of  each  of  the  major 
divisions  of  medicine  is  necessary  from  time  to  time  to  record  its  latest 
development  and  to  enable  those  who  desire  to  master  it  as  a  whole, 
or  to  post  themselves  on  special  points,  to  do  so  with  facility.  With 
this  object  three  companion  volumes  have  been  arranged  covering 
respectively  Gynecology,  Obstetrics,  and  Pediatrics,  and  furnishing  a 
compact  presentation  of  the  world's  best  knowledge  upon  these  closely 
connected  departments. 

The  volume  on  Pediatrics,  now  in  the  reader's  hands,  is  from  the  pens 
of  well-known  authorities  in  America  and  England,  who  have  been 
selected  as  eminently  fitted  to  write  on  the  subjects  assigned  to  them. 
These  authors  have  kept  in  mind :  first,  the  clinical  picture  of  a  disease, 
and  second,  the  best  methods  for  its  treatment.  This  plan  has  allowed 
each  author  to  give  his  own  observations  of  a  disease,  and  the  thera- 
peutic measures  which  have  resulted  in  the  greatest  success.  Naturally 
this  adds  to  each  contribution  a  personal  element  which  is  entitled  to 
consideration,  as  the  authors  are,  without  exception,  clinicians  and 
teachers  of  wide  experience. 

In  the  arrangement  of  the  volume  more  space  than  usual  has  been 
allotted  to  infant  feeding,  diseases  of  the  alimentary  tract,  disorders 
of  nutrition,  respiration,  and  circulation,  and  to  contagious  diseases, 
the  object  being  to  describe  the  conditions  most  intimately  associated 
with  disease  in  children  and  not  those  which  are  more  common  in 
adult  life  and  found  but  rarely  in  childhood.  In  a  word,  the  line 
between  Pediatrics  and  General  Medicine  has  been  carefully  drawn,  so 
that  space  has  thereby  been  found  for  a  full  presentation  of  this  specialty 
m  a  convenient  volume.  In  some  sections  extra  space  has  been  given 
to  methods  of  diagnosis  which  are  now  regarded  as  essential  by  physi- 
cians who  wish  to  be  exact  in  their  work,  but  the  details  of  which  are 
not  readily  accessible  elsewhere.  On  the  other  hand,  mooted  patho- 
logical questions  have  been  omitted,  and  the  pathology  stated  by  each 

(V) 


vi  PREFA  CE 

author  is  limited  to  what  is  regarded  as  essential  for  a  comprehensive 
knowletlge  of  the  ihsease  with  which  it  is  associated. 

The  Editor's  thanks  are  (hie  to  the  authors  for  their  contributions 
and  for  the  care  they  have  taken  in  revising  their  articles.  Thanks 
are  also  due  to  Dr.  Martha  Wollstein,  Pathologist  to  the  Babies'  Hos- 
pital, New  York,  and  to  Dr.  David  Bovaird,  Jr.,  one  of  the  contributors, 
for  their  valual)le  aid.  To  the  Publishers,  who  have  co-operated 
in  making  the  volume  attractive  in  every  way,  the  Editor  wishes  to 
express  his  appreciatic^n  for  the  many  courtesies  they  have  extended. 

W.  L.  C. 
New  York,  1906. 


LIST  OF  CONTRIBUTOES. 


ISAAC  ARTHUR  ABT,  M.D.,  Assistant  Professor  of  Pediatrics  in  the  Rush  Med- 
ical College  (University  of  Chicago) ;  Attending  Ph\'sician,  Diseases  of  Children, 
in  the  Michael  Reese  and  Cook  County  Hospitals;  Consulting  Phj^sician  to  the 
Provident  Hospital  and  Home  for  Crippled  Children,  Chicago,  111.;  ^leniber  of 
the  American  Pediatric  Society. 

DAVID  BOVAIRD,  Jr.,  A.B.,  M.D.,  formerly  Pathologist  to  the  Foundling  Hos- 
pital; Attending  Phj'sician  to  the  Seaside  Hospital  of  St.  John's  Guild,  Attend- 
ing Physician  to  the  New  York  City  Children's  Hospitals  and  Schools;  Associate 
Physician  to  the  Presbj^terian  Hospital,  New  York. 

FLOYD  M.  CRANDALL,  M.D.,  Consulting  Physician  to  the  New  York  City  Chil- 
dren's Hospitals  and  Schools:  Late  Visiting  Physician  to  the  Mintuna  Hospital 
for  Contagious  Diseases,  New  York;  Member  of  the  .Ajnerican  Pediatric  Society. 

CHARLES  TOWNSHEND  DADE,  M.D.,  Consulting  Dermatologist  to  the  Man- 
hattan State  Hospital;  Dermatologist  to  the  New  York  City  Children's  Hos- 
pitals and  Schools;  Dennatologist  to  the  Vanderbilt  Clinic,  College  of  Physi- 
cians and  Surgeons;  ^Member  of  the  New  York  Dermatological  Society,  New  York. 

EDWARD  P.  DAVIS,  A.M.,  M.D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical 
CoUege  and  the  Philadelphia  Polyclinic;  Ob.stetrician  to  the  Jefferson,  Phila- 
delphia, and  Polyclinic  Hospitals;  Consulting  Obstetrician  to  the  Preston 
Retreat,  Philadelphia;  Member  of  the  American  Pediatric  Society. 

CHARLES  GODWIN  JENNINGS,  M.D.,  Professor  of  the  Practice"  of  ^Medicine 
and  Diseases  of  Children  in  the  Detroit  CoUege  of  Medicine,  Detroit,  Mich. ; 
Member  of  the  American  Pediatric  Society. 

DANIEL  J.  McCarthy,  A.B.,  M.D.,  Professor  of  Medical  Jurisprudence  in  the 
t'niversity  of  Pennsylvania;  Associate  in  Medicine  in  William  Pepper  Clinical 
Laboratory  of  the  LTniversity  of  Pennsylvania;  Neurologist  to  the  Henry  Phipps 
Institute;  Neurologist  to  Philadelphia  General  Hospital(Blockley),  Philadelphia. 

MATTHIAS  NICOLL,  Jr.,  A.B.,  M.D.,  Visiting  Physician  to  the^Willard  Parker 
and  Riverside  Hospitals;  Instructor  in  Pediatrics  and  Intubation  at  the  LTni- 
versity and  Bellevue  Hospital  ]\Iedical  College;  Phj'sician  to  Bellevue  Hospital 
(Out-door  Department)  for  Diseases  of  Children;  Pathologist  in  the  New  York 
Foundling  Hospital,  New  York. 

F.  JOHN  POYNTON,  M.D.,  F.R.C.P.  Lond.,  Subdean  of  the  Medical  Faculty  of  the 
University  College,  London ;  Assistant  Physician  to  University  College  Hospital, 
and  to  the  Hospital  for  Sick  Children,  Great  Ormond  Street,  London,  England. 

CLR^E  RIVIERE,  M.D.  Lond.,  M.R.C.P.  Lond.,  :\I.R.C.S.  Eng.,  Assistant  Physi- 
cian in  the  East  London  Hospital  for  Children;  Phvsician  to  the  Out-patient 
Department  City  of  London  Hospital  for  Diseases  of  the  Chest,  London,  England. 

JOHN  RUHRAH,  M.D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the  College 
of  Physicians  and  Surgeons;  Visiting  Physician  to  the  Baltimore  City  Hospital, 
to  the  Robert  Garrett  Free  Hospital  for  Children,  and  to  the  Nursery  and  Child's 
Hospital,  Baltimore,  Md. ;  ^lember  of  the  American  Pediatric  Societv. 

THOMAS  S.  SOUTHWORTH,  A.M.,  M.D.,  Attending  Physician  to  the  New  York 
City  Children's  Hospitals  and  Schools,  Nursery  and  Child's  Hospital,  and  Min- 
turn  Hospital  for  Contagious  Diseases,  New  York;  ^lember  of  the  American 
Pediatric  Society. 

GEORGE  M.  TUTTLE,  A.B.,  M.D.,  Professor  of  Therapeutics  in  the  Medical 
Department  of  Washington  University;  Attending  Physician,  St.  Luke's  Hos- 
pital, the  Martha  Parsons  Children's  Hospital,  and  tlae  Bethesda  Foundling 
Asylum,  St.  Louis,  Mo. 

LEROY  MILTON  YALE,  A.M.,  M.D.,  formerly  Lecturer  on  Diseases  of  Children 
in  the  Belle^'ue  Hospital  Medical  College,  New  York;  Member  of  the  American 
Pediatric  Society. 

(vii) 


CONTENTS. 


SECTION   I. 

DISEASES  AND  INJURIES  OF  THE  NEWBORN. 
CHAPTER  I. 

PAGE 

THE  NORMAL  INFANT— THE  PREMATURE  INFANT      ...         .17 

By  Edward  P.  Davis,  M.D. 
CHAPTER  II. 

ASPHYXIA  NEONATORUM-ACCIDENTS  TO  THE  UMBILICAL  CORD      34 

By  Edward  P.  Davis,  M.D. 

CHAPTER  III. 
INJURY  AT  BIRTH— INFECTIONS        .  ......      41 

By  Edward  P.  Davis,  M.D. 


SECTION   II. 

DEVELOPMENT,  GROWTH,  AND  HYGIENE. 
CHAPTER  IV. 

CHANGES  AFTER  BIRTH— HYGIENE  OF  THE  INFANT  AND  NURSERY     61 

By  Leroy  Milton  Yale,  M.D. 
CHAPTER  V. 

GROWTH  AND  HYGIENE 70 

By  Leroy  Milton  Yale,  M.D. 

(ix) 


X  CONTENTS 

SECTION  TIT. 

INFANT  FF:EDING. 
CHAlTHi;  VI. 

PAGE 

MATERNAL  FEEDING— WEANING 89 

JiY  Thomas  S.  Sof^TiiwoRTii,  M.D. 

CIIAITKK   Vri. 

COWS'  MILK 107 

Ev  Thomas  8.  Soitthwouth,  M.I). 
CHAPTER  VIII. 

SUBSTITUTE  INFANT  FEEDING -FEEDING  AFTERTHE  FIRST  YEAR     123 

By  Thomas  S.  Southworth,  M.I). 


SECTION    IV. 

DISEASF^S  OF  THE  ALIMENTARY  TRACT. 
CHAPTER  IX. 

DISEASF.S  OF  THE  MOUTH  AND  PHARYNX 175 

By  David  JiovAiiiD,  Jr.,  M.D. 

CHAPTER  X. 

DISEASES  OF  THE  STOMACH 196 

By  David  Bovaird,  Jr.,  M.D. 
CHAPTER  XI. 

ACUTE  GASTROENTERIC  INFECTIONS 225 

By  David  Bovaird,  Jit.,  M.D. 

CHAPTER  XII. 

THE    DIARRHEAS  OF  INFANCY   AND  CHILDHOOD— DISEASES  OF 

THE  INTESTINES 242 

By  David  Bovaird,  Jr.,  M.D. 


CONTENTS  xi 

CHAPTER  XIII. 

JAUNDICE,  DISEASES  OF  THE  LIVER,  INTUSSUSCEPTION,  APPEN- 
DICITIS, DISEASES  OF  THE  PERITONEUM,  INTESTINAL  PARA- 
SITES    282 

By  David  Bovaird,  Jr.,  M.D. 


SECTION    V. 

DISEASES  OF  NUTRITION. 
CHAPTER  XIV. 

RACHITIS-SCORBUTUS— MARASMUS 321 

By  George  M.  Tuttle,  M.D. 


SECTION   VI. 
INFECTIOUS  DISEASES. 

CHAPTER  XV. 
TUBERCULOSIS 343 

By  Isaac  A.  Abt,  M.D.,  David  Bovaird,  Jr.,  M.D.,  and 
D.  J.  McCarthy,  M.D. 

CHAPTER  XVI. 

DIPHTHERIA 385 

By  Matthias  Nicoll,  Jr.,  M.D. 
CHAPTER  XVII. 

TYPHOID  FEVER— MALARIA— EPIDEMIC  CEREBROSPINAL  MENIN- 
GITIS—INFLUENZA  427 

By  Isaac  A.  Abt,  M.D.,  John  Ruhrah,  M.D.,  D.  J.  McCarthy,  M.D., 
AND  Matthias  Nicoll,  Jr.,  M.D. 

CHAPTER  XVIII. 

WHOOPING-COUGH-MUMPS— GLANDULAR  FEVER    .         .        .         -472 

By  Matthias  Nicoll,  Jr.,  M.D.,  and  Floyd  M.  Crandall,  M.D. 


xii  CONTENTS 

CHAITKK   XTX. 

PACK 

SCARLET  FEVER -JSG 

By  ri>OVl)    M.  CUANDALL,  M.I). 

CHAPTER  XX. 

ME.\SLES— RUBELLA— FOURTH     DISEASE— ERYTHEMA    INFECTI- 

OSUM '"ilQ 

By  Floyd  M.  Cuandall,  M.I>.,  am>  .I«»hn  Ruhrah,  M.D. 

(IIAPTKK  XXI. 

VARICELLA— VACCINL\— SMALLPOX 641 

By  Floyd  M,  Crandall,  M.J). 

CHAPTER  XXII. 
CONGENITAL  SYPHILIS— RHEUMATISM 563 

By  George  M.  Tuttle,  M.D.,  and  John  Ruhrah,  M.D. 


SECTION   VII. 

DISEASES  OF  THE  RESPIRATORY  TRACT. 
CHAPTER  XXIII. 

DISEASES  OF  THE  NOSE— NASOPHAIiYNX— LARYNX  .        .        .     585 

By  Clive  Riviere,  M.D. 

CHAPTER  XXIV. 

THE  LUNGS  IN  EARLY  CHILDHOOD— BRONCHITIS— PULMONARY 

COLLAPSE— BRONCHIAL  ASTHMA 601 

By  Clive  Riviere,  M.D. 
CHAPTER  XXV. 

BRONCHOPNEUMONIA— LOBAR  PNEUMONIA 617 

By  Clive  Riviere,  M.D. 
CHAPTER  XXVI. 

PLEURISY— EMPYEMA— PNEUMOTHORAX 646 

By  Clive  Riviere,  M.D. 


CONTENTS  xiii 


CHAPTER   XXVII. 


ABSCESS  OF  THE  LUNG— GANGKENE  OF  THE  LUNG— BRONCHI- 
ECTASIS AND    PULMONAEY    FIBROSIS-FOREIGN   BODIES  IN 


THE  AIK  TUBES 


By  Clive  Riviere,  M.D. 


666 


SECTION  YIII. 

DISEASES  OF  THE  HEART  AND  BLOODVESSELS. 

CHAPTER  XXVIII. 

METHOD    OF    EXAMINATION— CONGENITAL     HEART    DISEASE- 
RHEUMATIC  HEART  DISEASE 683 

By  F.  J.  PoYNTON,  M.D. 
CHAPTER  XXIX. 

CHRONIC  RHEUMATIC  HEART  DISEASE-TREATMENT  OF  RHEU- 
MATIC HEART  DISEASE  "^^2 

By  F.  J.  PoYNTON,  M.D. 
CHAPTER  XXX. 

HEART  DISEASE  FROM  DIPHTHERIA  AND  OTHER  INFECTIONS- 
DISEASES  OF  THE    ARTERIES 740 

By  F.  J.  Poynton,  M.D. 


SECTION   IX. 

DISEASES  OF  THE  GENITOURINARY  SYSTEM. 
CHAPTER  XXXI. 

URETHRITIS- VULVOVAGINITIS-DISEASES  OF    THE  BLADDER- 
DISEASES  OF  THE  KIDNEYS         '^^^ 

By  Charles  G.  Jennings,  M.D. 


^Iy  contents 


SECTION    X. 

DISEASED  OF  THE  FU.OOD.  LYMPHATIC  SYSTEM  AND  GLANDS. 
CJIAlTKi;  XXXIT. 


i'a«;e 


THE  BLCKin  —  ANEML\  —  CHLOROSIS  —  LEUKEMIA  —  PrKPUKA  — 

HEMOPHILIA ^'^''' 

JJv  .loiiN  KrnuAii,  M.I). 

CllAlTKllXWIlI. 
THE    THYMUS— STATUS     LYMPHATICUS-ADENITIS-HODGKIN'S 


DISEASE— THE  SPLEEN 


836 


]5v  .loiiN  liiHi:.\n,  M.l). 


CHAlTEIi  XXXIV. 


THE     ADRENALS- ADDISON'S      DISEASE-CRETINISM-DIABETES 

MELLITUS ^"^^ 

By  John  Uuiiuah,  M.D. 


sp:ction  XI. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

CHAPTER  XXXV. 

FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM— CONVULSIVE 

DISORDERS  ««51 

By  I).  J.  McCakthy,  M.I). 

chaptp:rxxxvi. 

ORGANIC  NERVOUS  DISEASES— DISEASES  OF  THE  NERVES  AND 

SPINAL  CORD— ABIOTROPHIC  DISEASES 885 

ByD.  J.  McCarthy,  M.D. 
chapter  XXXVII. 

DISEASES  OF  THE  BRAIN  AND  MENINGES 929 

By  D.J.  McCarthy,  M.D. 


CONTENTS  XV 

SECTION  XII. 

DISEASES  OF  THE  SKIN. 


CHAPTER  XXXVIII. 

-UETICAEIA— IMPETIGO- 

By  Charles  Townshend  Dade,  M.D. 


PAGE 

ECZEMA— ERYTHEMA— UETICAEIA— IMPETIGO— SCABIES         .         .    969 


SECTION  I. 
DISEASES  AND  INJURIES  OF  THE  NEWBORN. 

By  EDWARD  P.  DAVIS,  M.D. 


CHAPTER   I. 

THE  NORMAL  INFANT— THE  PREAIATURE  INFANT. 
THE  NORMAL  INFANT. 

In  order  to  understand  the  normal  infant  so  as  to  appreciate  patho- 
logical conditions  it  may  be  well  briefly  to  consider  the  characteristics 
of  the  viable  infant  at  full  term. 

Size  and  Weight. — Various  criteria  of  viability  have  been  consid- 
ered important.  The  length  of  the  finger-nails,  growth  of  hair  on  the 
head,  brightness  and  clearness  of  the  eyes,  weight,  and  the  ability  of  the 
infant  to  nurse  and  to  cry  have  been  regarded  as  affording  an  accurate 
basis  for  the  recognition  of  viability.  Infants,  however,  differ  so  much 
in  development  that  some  more  accurate  data  than  these  must  be 
obtained  for  scientific  judgment. 

Diihrssen's  table,  giving  the  length  of  the  fetus  at  different  periods 
of  gestation,  has  been  commonly  accepted  as  practically  accurate.  By 
this  we  find  that  at  six  months  the  fetus  is  30  cm.  (llf  in.)  long,  at  seven 
months  35  cm.  (13f  in.),  at  eight  months  40  cm.  (15f  in.),  at  nine  months 
45  cm.  (17f  in.),  and  at  ten  months  50  cm.  (19f  in.)  long.  The  earliest 
recorded  period  of  viability  is  twenty -six  weeks,  and  at  this  time  the 
fetus  of  average  development  should  be  32  cm.  (12^  in.)  in  length. 
The  difference  between  the  length  of  the  viable  fetus  and  the  length 
of  the  fetus  at  full  term  is  sufficiently  great  to  show  that  many  infants 
may  be  born  viable  and  yet  sometime  removed  from  full  development. 

In  estimating  the  degree  of  development  of  the  newborn  infant  we 
may  have  reference  to  the  proportionate  length,  chest  circimiference, 
and  cranial  circumference.  Thus,  if  the  length  be  50  cm.  (19f  in.)  the 
circumference  of  the  chest  is  half  this  plus  10  cm.,  or  35  cm,  (13f  in.), 
and  the  circumference  of  the  cranium  is  2  or  3  cm.  greater,  or  37  or 
38  cm.  (14^  to  M^^Q  in.).  Essential  variations  from  these  proportions 
indicate  lack  of  development  and  in  some  cases  disease. 

2  (17) 


18  DISEASES  A  \i>  /\./r/,7/-;N  OF  Till-:  \i-:\yiu)U'\ 

'V\\v  iivfi-a^'c  \vt'iti;lit  of  full-tt-rm  iiiiilr  iiifaiils  .")()  cm.  (I!);-|  in.)  lonj; 
is  ;i274.1()  <,'rains;  of  ft-inale  infants  11)  cm.  (19,!  in.)  loIl<,^  '.i\  12.S()^rram.s. 
As  a  fj;cncral  criterion  of  (leveloj)ment  Jung'  observed  that  in  well- 
developed  or  full-term  infants  the  circumference  of  the  shoulders  equalled 
or  exceeded  the  oc(ij)itofr()ntal  diameter  of  the  head. 

In  considerini^  the  char.icteristics  of  an  infant  at  full  term,  Herz^ 
found,  in  fully  developed  infants,  lanu<^o  widely  develoj)e(l  over  the 
entire  i)0(ly.  He  also  oh.served  tliat  comedones  were  present  upon  the 
face  in  hut  5.7  per  cent,  of  full-term  infants  outside  the  region  of 
the  nose  and  h'j)s,  while  in  premature  infants  they  extended  over  the 
entire  face  in  S'SM  percent,  'riie  skin  of  a  normal  infant  is  reddened 
and  covered  in  many  parts  by  vernix  ca.seosa.  After  removal  of  the 
vernix  caseo.sa  the  skin  gradually  becomes  more  pinkish  in  color.  In 
premature  infants  the  mammary  glands  are  much  less  developed  than 
in  full-term  infants,  secretion  forming  much  later  or  not  at  all. 

Umbilicus. — The  portion  of  umbilical  cord  remaining  attached  to 
the  newljorn  infant  is  its  only  visii)le  remnant  of  intrauterine  existence, 
and  this  undergo:^s  necrosis  and  separates  from  the  infant  between  the 
sixth  and  eighth  days  of  life.  While  the  umbilical  cord  is  free  from 
bacteria  at  birth,  mimerous  micro-organisms  make  their  appearance  in 
the  stumj)  within  five  or  six  hours.  Among  the  j)athogenic  bacteria 
present  are  the  staphylococcus  pyogenes  albus,  citreus,  and  aureus. 
The  number  of  bacteria  is  less  in  infants  who  are  not  bathed  daily  than 
in  tho.se  who  are.  In  view  of  such  observations  it  becomes  evident 
that  the  closure  of  the  umi)ilical  ves.sels  must  play  an  important  part 
in  the  prevention  of  infection  with  these  bacteria. 

The  Blood. — The  blood  of  the  newborn  infant  presents  .several  char- 
acteristic features:  the  number  of  red  cells  is  (5,000 ,()()()  to  7,000,000  per 
cubic  millimetre,  of  leukocytes  about  18,030;  the  hemoglobin  i)er  cent, 
is  always  ai)ove  100  and  may  reach  120;  the  specific  gravity  is  lOOO; 
nucleated  red  corj)uscles  are  present  in  the  proportion  of  ^-q  to  ^  of  the 
total  number  of  leukocytes,  and,  finally,  the  hemolytic,  bactericidal, 
anil  agglutinating  jxnver  of  the  infant's  blood  serum  is  far  less  marked 
than  in  later  life. 

Within  two  weeks  the  red  cells  diminish  from  r),()()(),0()()  to  4,r)0(),()(:0 
per  cubic  millimetre,  the  leukocytes  to  10,000,  and  the  nucleated  red 
cells  also  fliminish  in  numbers.  The  lymphocytes  number  three-fourths 
to  two-thirds  of  the  total  leukocytes. 

Scipiade.s'^  found  that  both  red  and  wliite  cells  diminish  during  the 
first  ten  days  and  this  is  e(|ually  true  whether  infants  are  bathed  or 
not  l)athed.  There  is,  however,  after  the  initial  lo.ss  of  w'cight  a  greater 
gain  in  blood  cells  in  bathed  infants  than  in  those  who  are  not  bathed. 
Late  ligation  of  the  cord  does  not  prevent  the  early  loss  of  cells,  but 
in  the  long  run  it  increases  the  volume  of  the  fetal  blood,  and  hence  is 
indicated. 

'  Inaugural  Dis.sertation,  Bern,  1902. 

*  Klin.  UntersuchuiiKen  an  100  Neugeboren,  Inaug  Diss.,  Freiburg. 

»  Archiv  f.  Gynak.,  1903,  Band  Ixx. 


THE   NORMAL   INFANT  19 

Circulation. — Immediately  after  birth  the  heart  beat  does  not  differ 
materially  from  that  which  was  heard  within  the  womb.  The  impulse 
of  the  heart  may  be  plainly  felt  by  placing  the  finger-tips  over  the 
precordium.  The  reddish  color  of  the  baby's  skin  shows  that  oxy- 
genation is  going  on  and  that  asphyxia  is  absent.  The  pulse  of  a 
newly  born  infant  varies  from  the  first  minute  of  birth.  It  may  fall 
20  or  30  beats  and  then  be  accelerated  beyond  the  fetal  rate.  Usually 
it  falls  10  to  30  beats,  but  the  rate  is  easily  increased. 

As  Ballantyne  remarks,  the  physiological  transition  from  the  fetal  to 
the  postnatal  form  of  circulation  is  no  doubt  very  rapid,  but  the  ana- 
tomical transition,  evidenced  by  the  obliteration  of  the  lumina  of  the 
ductus  arteriosus,  foramen  ovale,  umbilical  vessels,  and  ductus  venosus 
may  not  be  complete  for  some  days  or  even  weeks. 

Respiration. — Respiratory  movements  of  the  newborn  are  at  first 
abdominal  and  become  thoracic  only  as  the  lungs  expand.  It  is  a 
question  whether  the  use  of  the  abdominal  binder,  by  impeding  the 
movements  of  the  abdominal  muscles,  stimulates  or  retards  the  full 
development  of  respiration.  The  healthy  full-term  infant,  so  soon  as 
its  nostrils  are  freed  from  mucus,  can  breathe  with  the  mouth  shut  and 
frequently  does  so.  Persistent  failure  on  the  part  of  the  infant  to  close 
the  mouth  during  respiration  indicates  some  abnormality  in  the  nose 
or  throat.  The  respiratory  rate  of  the  newborn  is  relatively  high — from 
30  to  45  per  minute — but  as  the  lungs  expand  it  gradually  falls.  The 
condition  known  as  atelectasis  may,  in  premature  and  weak  infants, 
be  the  cause  of  delayed  aeration.  The  first  cry  of  the  infant  plays  an 
important  part  in  expanding  the  lungs. 

The  full-term  infant  is  able  to  suck  vigorously.  The  fact  that  the 
infant  can  close  its  mouth  on  the  nipple  and  keep  the  mouth  closed  for 
some  moments  shows  that  no  pathological  condition  of  moment  exists 
in  the  nose  or  throat.  When  the  baby  drops  the  nipple  to  cough  or 
becomes  restless  and  disturbed  during  the  effort  to  nurse,  abnormality 
or  disease  in  the  respiratory  tract  should  be  suspected,  and  a  proper 
examination  made. 

The  Temperature. — The  temperature  of  the  fetus  within  the  uterus 
has  been  ascertained  by  measurement  to  be  above  100°  F.  The  average 
temperature  of  the  newborn  is  99.5°  to  100.2°  F.  There  is  a  daily  fluc- 
tuation from  one-tenth  to  three-tenths  of  a  degree.  The  temperature 
of  the  newborn  falls  after  the  first  bath,  and  it  must  vary  greatly  in 
accordance  with  the  precautions  taken  or  the  lack  of  care  in  preventing 
exposure  to  cold.  It  is  hot  definitely  known  how  low  the  temperature 
of  the  newborn  can  fall  and  not  occasion  death,  but  in  my  observation 
a  newborn  child  was  exposed  on  a  winter's  night  for  several  hours, 
and  survived. 

Kidney  Action. — Ferroni^  examined  the  urine  of  ninety-two  newborn 
infants  during  the  first  week  of  life,  and  believes  that  the  character  of 
this  urine,  the  anatomical  arrangement  of  the  kidneys  and  the  mechanical 

1  Annali  di  Ost.  e  Gin.,  1902,  p.  75. 


20  DISEASES  A\D   l.XJili'lES   OF   THE   \EWBORN 

conditions  in  the  circulation  of  the  newborn  show  that  a  true  ki(hiey 
function  could  not  have  been  present  in  intrauterine  life.  A  <feiuiine 
secretion  of  urine  tloes  not  take  place  until  the  third  day.  After  the 
fourth  day  renal  function  is  established.  Nevertheless,  Hallantyne 
believes  that  there  is  no  room  left  for  doubt  that  the  fetal  kidneys 
are  at  leiist  occasionally  active  durinfij  fetal  life.  Albumin,  casts,  and 
uric  acid  are  frecjuently  present,  and,  in  a  few  cases,  sugar  may  be 
detected.  The  specific  gravity  of  the  urine  varies  between  1004  and 
1010.  When  the  specific  gravity  is  lower  the  urine  is  less  acid  and  the 
albumin  and  casts  disappear.  In  ten  cases  Ferroni  examined  the  urine 
of  the  newborn  by  cryoscopy.  The  results  gave  a  proj)ortion  of  1.57. 
The  urine  of  six  newborn  infants  was  studied  to  ascertain  its  toxic 
effects.  This  was  found  to  be  greater  than  that  of  the  urine  of  older 
nursing  children  or  of  partly  grown  children  or  adults.  The  greatest 
ilegree  of  toxicity  was  present  on  the  third  or  fourth  day. 

Stomach  and  Intestines. — The  stomach  is  coiuparativcly  small  and 
is  more  vertical  than  in  the  adult.  Rotch  {Pcdiatricfi)  shows  a  stomach 
with  a  capacity  of  25  c.c.  (f  oz.),  while  the  infant  weighed  2500  gms. 
(52  lbs.).  The  pylorus  is  situated  immediately  in  front  of  the  first 
lumbar  vertebra.  Anteriorly  the  stomach  is  in  contact  with  the  left  under 
surface  of  the  liver,  while  posteriorly  it  lies  against  the  anterior  surface 
of  the  spleen.  The  relations  indicate,  in  part,  the  difference  in  its 
position  in  early  infancy  from  those  described  in  childhood.  The 
greater  curvature  is  over  the  transverse  colon,  which  is  often  not  definitely 
transverse.  The  whole  intestinal  canal  is  loosely  attached  to  the  posterior 
wall  of  the  abdomen.  The  large  intestine  is  more  freely  movable  than 
the  small.  The  appendix  at  birth  usually  measures  from  3  to  5  cms. 
(1  to  2  in.)  in  length. 

The  newborn  baby  gives  evidence  of  the  condition  of  the  intestines 
by  the  passage  of  meconium.  This  is  made  up  of  swallowed  licjuor 
amnii,  lanugo  hairs,  vernix  caseosa,  epithelial  cells  from  the  skin  and 
intestinal  mucosa,  bile,  mucus,  succus  entericus,  and  pancreatic  secre- 
tion. The  absence  of  bile  indicates  obstruction  of  the  bilenlucts. 
Microscopically,  blood  corpuscles  and  crystals  of  bilirubin  and  bili- 
verdin  are  found. 

Weight  of  Organs. — Legou^  has  investigated  the  proportionate  weight 
of  the  various  organs  of  the  newborn.  The  upper  extremities  are  in 
the  same  relation  to  the  bofly  as  in  the  adult,  but  the  lower  extremities 
are  much  less  developed.  The  heart  weighs  relatively  one-fourth  more 
than  in  the  adult;  the  liver  is  one-third  larger.  The  proportion  between 
the  size  of  the  spleen  and  that  of  the  remainder  of  the  body  in  the  fetus 
at  term  is  the  same  as  in  the  adult.  The  kidneys  are  one-third  larger 
than  in  the  adult,  and  at  seven  months'  gestation  the  suprarenal  capsules 
are  proportionally  fifteen  times  greater  than  in  the  adult  individual. 
From  the  sixth  month  on  the  brain  of  the  fetus  is  larger  in  proportion 
than  that  of  the  adult.     The  thymus  gland  is  relatively  large  and  varies 

1  These  de  Paris,  1903,  No.  179. 


THE   NORMAL   IXFAXT  21 

in  weight  from  S  to  13  gms.  (2  to  3-g-  dr.);  its  relationship  to  the  body 
weight  is  1  to  250  to  1  to  350. 

Influence  of  Nursing.— The  act  of  sucking  calls  for  increased  respir- 
atory effort  and  so  furthers  the  unfolding  of  the  lungs,  while  the  move- 
ment of  sucking  assists  indirectly  in  promoting  the  establishment  of  the 
circulation.  ^Vhile  we  recognize  nursing  as  an  important  agent  in 
promoting  the  interest  of  the  mother,  we  must  not  forget  that  aside 
from  the  question  of  nutrition  nursing  has  value  in  establishing  the 
essential  functions  of  respiration  and  circulation  in  the  infant 

Care  at  Birth. — The  change  in  the  infant's  surroundings  which  birth 
produces  must  under  the  best  conditions  be  very  great.  Care  should 
be  taken  that  the  room  be  suitably  warm,  the  infant  wrapped  in  a  warm 
blanket  and  given  artificial  lieat.  ^Miile  the  hot-water  bag  is  ordinarily 
sufficient  it  must  be  remembered  that  if  the  infant's  body  be  moist  or  the 
bag  leaks  a  severe  burn  may  result.  It  is  safer  to  surround  the  newborn 
infant  with  warmth  which  is  perfectly  dry. 

As  the  blood  of  the  newborn  is  excessive  in  hemoglobin  it  has  no 
immediate  need  of  respiration,  after  the  act  is  once  established,  to  main- 
tain oxygenation.  Hence,  the  head  may  be  covered  with  a  wrap  of  light 
flannel  extending  over  the  greater  portion  of  the  head  and  face. 

The  aseptic  care  of  the  cord  is  a  matter  of  immediate  importance, 
and  is  accomplished  by  ligating  it  firmly  and  by  wrapping  the  stump 
in  sterile  gauze.  The  vessels  of  the  cord  sometimes  slip  within  the 
ligature  and  secondary  hemorrhage  may  result.  An  additional  liga- 
ture may  be  required.  Care  should  be  taken  in  bathing  the  baby  that 
neither  bath  sponges  nor  bath  water  come  in  contact  with  the  cord, 
as  sterility  is  maintained  for  a  longer  period  when  it  is  kept  dry  and 
allowed  to  mummifv. 

The  eyes  must  be  flushed  with  boric  acid  solution.  A  2  per  cent. 
silver  nitrate  or  argyrol  from  1  to  10  per  cent,  may  be  used  if  there  is 
any  c(uestion  of  gonorrheal  infection. 

The  mouth  may  be  washed  with  boric  acid  solution.  That  respiration 
may  be  unimpeded  the  nurse  must  see  that  the  nostrils  and  mouth 
are  free  from  mucus.  The  effort  frequently  made  to  remove  mucus  by 
inserting  the  finger  wrapped  in  soft  linen  may  fail  and  instead  retained 
mucus  may  be  carried  farther  into  the  respiratory  passages.  Both 
circulation  and  respiration  will  be  aided,  where  these  functions  are 
slowly  established,  if  the  infant  be  held  for  a  moment  head  down- 
ward and  the  trunk  gently  folded  on  itself  anteriorly. 

The  secretion  of  urine  will  be  facilitated  by  giving  water  freely, 
thus  lessening  the  danger  of  uric  acid  infarctions  and  also  one  source  of 
high  temperature  which  is  seen  in  infants  who  pass  only  a  small  amount 
of  urine. 

The  common  practice  of  oiling  the  newborn  infant  to  further  the 
removal  of  the  vernix  from  its  skin  is  advantageous  if  combined  with 
gentle  massage  of  the  whole  body.  The  first  bath  of  the  newborn, 
unless  cautiously  employed,  may  be  a  source  of  infection  at  the  umbilicus, 
eyes,  or  mouth,  or  of  such  exposure  as  to  bring  about  an  attack  of 


22  DISEASES  A.\D  IXJURIES  OF   THE  NEWBORN 

pneumonia.  A  newborn  infant  should  not  be  tubbed,  Init  kept  between 
the  folds  of  a  flannel  apron  and  bathed  by  sponging  or  rubbing  with 
absorbent  gauze  or  cotton.  Separate  pieces  of  cotton  or  gauze  should 
be  used  for  the  face  and  head  and  for  otiier  portions  of  the  body. 
Bath-water  should  preferably  be  sterile,  of  moderate  temjierature,  and 
the  soap  employed  should  be  as  pure  as  possible.  If  a  newborn  infant 
be  rapidly  and  skilfully  bathed,  with  light  massage,  the  whole  process 
conduces  greatly  to  the  stimulation  of  its  vital  functions.  If  this  be 
badly  done  serious  injury  may  be  the  consec|uence. 

The  healthy  newborn  infant  gives  abundant  evidence  of  its  normal 
condition.  It  cries  but  little,  and  only  when  disturbed.  Its  sucking  or 
grunting  sound  gives  evidence  of  its  physical  contentment.  Its  roseate 
color  and  the  warmth  of  its  body  show  a  good  circulation.  Its  power 
to  swallow  and  to  suck  and  its  vigorous  cry  denote  its  strength.  Its 
disposition  to  sleep  when  undisturbed  gives  evidence  that  its  nervous 
system  is  not  harassed  by  pain,  cold,  or  other  discomfort. 


THE   PREMATURE  INFANT. 

From  viability  at  twenty-six  weeks  to  full  term  an  infant  is  said  to  be 
premature.  As  the  premature  infant  is  less  vigorous  than  the  full-term 
infant,  it  sustains  birth  pressure  less  perfectly.  In  premature  labor  the 
membranes  rupture  before  dilatation  is  complete  and  infection  is  more 
likely  to  occur.  Abnormal  presentations  expose  these  infants  to  the 
added  manipulation  necessary  to  effect  delivery.  Many  of  the  causes 
which  terminate  pregnancy  before  full  term  in  the  mother  are  conditions 
which  render  the  infant  feeble.  Those  diseases  which  produce  wasting 
and  weakness — e.  (/.,  tuberculosis  and  syphilis — in  the  mother  naturally 
weaken  the  child.  Acute  infections,  such  as  typhoid  fever,  which 
attacking  the  mother  bring  on  labor,  also  affect  the  infant.  Premature 
separation  of  the  placenta  with  intrauterine  hemorrhage  must  necessarily 
depress  the  infant.  Tiie  causes  enumeraterl  are  sufficient,  aside  from 
the  prematurity  of  the  infant,  to  render  it  more  feeble  than  normal  and 
to  make  a  prognosis  of  its  survival  guarded. 

Premature  infants  are  more  susceptible  to  the  depressing  influence  of 
cold,  and  also  to  infection  than  are  full-term  infants.  As  Ballantyne 
has  pointed  out,  the  circulation  of  premature  infants  is  unsatisfactory 
because  it  is  partly  fetal  and  partly  neonatal,  the  foramen  ovale  and  the 
ductus  arteriosus  tending  to  remain  patent  longer  than  is  normal  in 
infants  born  at  term,  and  in  consequence  the  two  blood  currents  are 
incompletely  separated. 

The  conditions  which  predispose  the  newborn  infant  to  infection 
have  been  most  fully  stated  by  Fischl.^  Foremost  among  them  is  the 
fact  that  phagocytosis  is  much  less  marked  than  in  later  life,  owing 
to  the  undeveloped  condition  of  the  lymph  nodes,  spleen,  and  bone- 

1  Traits  desmal.  de  I'Enf.,  par  Grancher  and  Comby,  T.  v.  p.  27. 


THE   PREMATURE   INFANT  23 

marrow.  The  desquamation  of  the  epithehal  cells  covering  the  skin 
and  mucous  membranes,  as  first  noted  by  Epstein,  decreases  the  power 
of  these  organs  to  resist  the  entrance  of  bacteria,  and  to  this  the  incom- 
plete development  of  the  corneous  layer  of  the  skin  (Hulot)  also  con- 
tributes. The  protective  power  of  the  blood  is  much  less  marked  than 
in  adults;  and,  finally,  the  closure  of  the  umbilical  vessels  is  apt  to  be 
incomplete,  and  thus  an  entrance  point  for  bacteria  is  present. 

Premature  infants  are  also  very  susceptible  to  drugs,  and  the  quantity 
which  would  be  safely  borne  by  a  full-term  infant  may  destroy  life. 
Observers  have  noted  the  extreme  susceptibility  of  premature  infants 
to  poisoning  with  bichloride  of  mercury  or  carbolic  acid  when  used  as 
a  wash. 

It  is  not  the  absence  of  weight  of  the  premature  infant  alone  which 
determines  its  vigor  or  its  possible  survival.  Some  of  the  smallest  prema- 
ture children  have  developed  best.  Thus,  Jardine^  reports  the  survival 
of  an  infant  born  prematurely  weighing  two  pounds.  Shepherd  saw 
a  similar  case.  "ManselP  reports  the  survival  of  a  premature  infant 
weighing  at  birth  eighteen  ounces,  and  in  my  own  observation  twins  were 
born  prematurely  whose  mother  had  been  weakened  by  pneumonia. 
The  boy  weighed  a  little  more  than  three  pounds,  the  girl  about  two 
and  three-quarters.  These  children  have  lived  to  be  ten  years  old,  and 
are  vigorous  and  well  developed. 

Adriance^  ascribes  the  weakness  of  premature  infants  to  deficient 
production  of  heat  and  the  fact  that  the  functions  of  the  lungs  are 
poorly  performed.  In  forty  premature  infants  under  his  observation 
twenty-four  died.  Thirteen  of  these  had  some  accident  or  disease  which 
could  be  referred  to  the  prematurity  of  the  infants  alone. 

In  deciding  if  the  infant  is  premature  we  must  not  rely  exclusively 
upon  the  weight,  the  appearance  of  the  nails  or  hair,  or  other  superficial 
criteria.  The  length  of  the  infant  is  far  more  reliable  as  a  basis  of 
judgment.  A  viable  and  premature  infant  will  be  at  least  31  or  32  cm. 
in  length.  Other  criteria  must  be  in  keeping  with  this  abnormal  lack  of 
development  in  length. 

Treatment.— The  treatment  of  these  infants  must  begin  with  the 
conduct  of  premature  labor  by  the  obstetrician,  who  must  exercise  care 
to  prevent  pressure  and  infection. 

Premature  infants  are  very  susceptible  to  the  change  in  temperature 
which  follows  birth.  The  rectal  temperature  of  a  fetus  in  the  uterus 
is  0.2  degree  higher  than  that  of  the  uterus  itself.  Under  the  most 
favorable  circumstances  the  premature  infant  at  birth  is  exposed  to  a 
change  of  temperature  of  20°  F. 

To  avoid  chill  a  warm  blanket  should,  if  possible,  be  thrown  over 
the  infant  so  soon  as  it  is  expelled  and  even  before  the  cord  has  been 
ligated.  If  the  infant  is  born  in  breech  presentation  the  trunk  and 
lower  extremities  should  be  wrapped  in  warm  sterile  flannel  or  other 

1  British  Medical  Journal,  1902,  vol.  i.  p.  654. 

2  Ibid.,  1902,  vol.  i.  p.  773. 

3  American  Journal  of  the  Medical  Sciences,  1901,  vol.  cxxi.  p.  410. 


24 


DISEASES  AM)   ISJURIES  OF   THE   SEWBORS 


warm  and  steriU'  material  (Fig.  1).  Immediately  after  birth  the  prema- 
ture infant  should  he  j)laced  in  a  warm  receptacle  and  artificial  heat 
placed  about  it.  Especial  care  is  necessary  to  j)rotect  the  premature 
infant  against  draughts  of  cold  air.  A  premature  infant  should  not  be 
bathed  immediately  after  birth,  as  in  the  ordinary  bath  exposure  is 
inevital)le,  and  these  infants  do  not  resist  infection  so  well  as  infants 
born  at  term. 

Physicians  and  nurses  should  avoid  handling  such  infants  with  cold 
hands.  It  will  not  do  to  trust  to  sensations  in  estimating  the  temperature 
of  wateror  the  air  of  the  room,  l)ut  the  thermometer  should  be  constantly 
employed. 

Fig.  1 


Incubator,  showing  infant  bandaged  with  cotton. 

Dress. — In  dressing  these  infants  the  first  care  of  the  physician  mu.st 
be  that  the  dress  be  thick,  warm,  comfortable,  (|uickly  applied,  and 
easily  changed.  A  warm  blanket  should  be  used  over  the  infant  before 
the  cord  is  cut.  The  infant  may  he  gently  but  thoroughly  cleaned 
beneath  a  warm  blanket  by  wiping  and  gently  rubbing  the  skin  with 
sterile  cotton  anointed  witli  sterile  olive  oil.  A  dressing  of  sterile  gauze 
or  cotton  may  be  retained  upon  the  .stump  of  the  umbilical  cord  by  a 
flannel  abdominal  binder. 

I  prefer  to  have  the  broad  abdominal  binder  applied  and  then  dress 
the  infant  in  a  loo.se  gown  or  sack  of  flannel,  without  sleeves,  which 
fastens  about  the  neck  and  which  is  gathered  below  the  limbs  like  a 
bag  (Fig.  2). 


THE  PREMATURE  INFANT 


25 


In  such  clothing  the  infant  can  move  freely  without  exposure  to  the 
air.  Absorbent  cotton  and  sterile  gauze  may  be  placed  over  the  orifice 
of  the  urethra  and  over  the  anus  to  receive  the  discharges  of  urine  and 
feces.  At  the  time  of  birth  it  is  well  to  flush  the  eyes  gently  with  sterile 
water  or  dilute  solution  of  boric  acid.  Crede  solution  of  silver  nitrate, 
2  per  cent,,  should  be  used  in  maternity  hospital  cases.  The  mouth 
may  be  gently  but  thoroughly  cleansed  with  the  softest  linen  dipped 
in  4  per  cent,  boric  acid  solution.  The  infant  should  be  given  a  tea- 
spoonful  of  warm  water  as  often  as  it  will  take  it. 

Incubators. — X  very  important  question  in  the  care  of  these  infants 
is  the  selection  of  a  suitable  receptacle.    This  must  be  so  arranged  that  a 


Fig.  2 


Incubator,  showing  infant  dressed  in  flannel  sleeping  bag. 

fairly  constant  artificial  heat  can  be  maintained.  For  the  first  twenty-four 
hours  95°  F.  are  desirable.  Unless  the  infant  shows  evidence  of  depres- 
sion from  this  temperature  it  may  be  continued  for  several  days.  The 
temperature  may  gradually  be  lessened  until  80°  F.  are  reached.  It  is 
usual  when  possible  to  place  premature  infants  in  incubators.  These  vary 
in  elaboration.  iVs  with  other  medical  appliances,  the  simplest  are  most 
satisfactory.  Ingenious  and  complicated  incubators  have  been  devised , 
many  of  which  have  apparatus  for  supplying  oxygen  to  the  infant  in 
addition  to  heat.  The  disadvantage  of  elaborate  incubators  lies  in 
their  tendency  to  be  infected  on  the  inner  surface.  Those  which  are 
heated  by  gas  do  not  furnish  a  favorable  atmosphere  for  the  infant.  Such 
incubators  are  extensively  advertised,  but  are  of  little  practical  value. 


20 


DISEASES  A\D   IXJlh'Ih'S  OF   THE   .\E]V BOILS 


If  a  permanent  incubator  l)e  desired  I  have  had  excellent  results  with 
the  use  of  Auvards  simple  one  (Fig.  3).  This  consists  of  a  cubical 
box,  across  three-fourths  of  which  extends  a  berth.  There  is  free  com- 
munication between  the  air  chamber  beneath  the  berth  and  the  berth 
itself  by  the  open  s|)ace  left  where  the  Hoor  of  the  berth  does  not  meet 
the  opposite  wall.  Beneath  the  berth  are  placed  coj)])er  cans  filled 
with  hot  water.  I  iiave  found  that  if  one  of  the.se  cans  be  changed  each 
hour  a  temperature  of  over  90°  F.  is  readily  maintained.     A  small  tni])- 


FlG,  3 


Incubator.  slKjwing  liot-waier  cans  and  arrangement. 

door  in  the  side  of  the  box  fartliest  from  the  opening  into  the  bertli  per- 
mits air  to  enter,  pa.ss  over  the  copper  cans,  and  rise  to  the  child  lying 
in  the  berth.  At  the  opposite  extremity  from  the  sj)ace  where  warm  air 
arises  a  copper  tube  an  inch  or  more  in  diameter  is  passed  through 
the  roof  of  the  box.  This  tube  may  contain  a  small  revolving  fan  kept 
in  motion  bv  the  constant  stream  of  heated  air  which  finds  egress 
through  the  tul)e.  As  the  fan  is  delicate  and  likely  to  break  down  I 
have  discarded  it,  using  tlie  simple  tul^e  alone.     A  constant  circulation 


THE  PREMATURE  INFANT 


27 


of  air  is  thus  maintained  in  the  simplest  manner  possible.  The  roof  of 
the  box  next  the  tube  is  largely  of  glass,  beneath  which  a  thermometer 
is  fastened.  The  box  should  not  be  placed  upon  the  floor  of  the  room, 
but  upon  a  table  or  two  chairs,  and  if  desired  it  may  be  placed  near  a 
window  or  ventilator  communicating  with  the  outside  air  to  secure  the 
best  possible  air  for  the  infant. 

If  a  simple  incubator  be  not  available  an  excellent  substitute  can  be 
improvised  by  taking  the  ordinary  wicker  clothes-basket  in  which  clean 
linen  is  commonly  placed  (Fig,  4).  Several  cans  filled  with  hot  water  or 
tightly  corked  bottles  should  be  placed  upon  the  bottom  of  the  basket. 
A  large  warm  blanket  folded  several  times  should  line  the  floor  and  sides 


Fig.  4 


Clothes-basket  prepared  for  use  as  an  incubator. 

of  the  basket  above  the  bottles.  A  thermometer  should  be  tied  to 
the  inside  of  the  basket,  so  that  it  can  be  readily  seen  and  measure 
the  temperature  of  the  interior  of  the  basket.  Additional  blankets 
may  be  used  to  line  the  basket  thoroughly  and  a  blanket  of  medium 
weight  should  be  placed  over  it.  The  infant  should  be  placed  upon 
the  blanket  in  the  basket  above  the  cans  or  bottles.  Sufficient  space 
should  be  left  in  the  covering  to  permit  the  free  entrance  of  air.  The 
basket  should  be  placed  upon  a  high  table  in  a  well-ventilated  room 
and  not  crowded  into  a  corner  or  over  a  register.  A  temperature 
of  90°  F.  or  more  may  be  readily  maintained  with  this  simple  device 
by  changing  one  or  two  of  the  bottles  in  the  bottom  of  the  basket  at 


28  DISEASES  A.\D  IXJURIES  OF   THE  XEWBORN 

regular  intervals.  If  desired  a  hot-water  bag  covered  with  flannel  may 
be  placed  in  the  basket  next  the  infant.  A  basket  so  prepared  is  almost 
invariably  available,  is  readily  fitted,  and  answers  every  practical  purpo.se. 

While  theoretically  it  would  be  desirable  to  supply  the  premature 
infant  with  oxygen,  practically  it  is  difficult  to  carry  out  and  rarely 
nece-ssary.  With  tlie  basket  inculiator  it  would  be  difKcult  to  introduce 
oxygen  gas  within  the  basket  in  sufficient  ([uantity  to  benefit  the  child. 
Practically,  if  the  air  of  the  room  be  kept  fresh  and  not  above  70°  F., 
and  the  blanket  be  not  too  closely  applied,  the  infant  will  obtain  oxygen 
sufficient.  In  mild  weather  the  blanket  covering  the  basket  may  be 
discarded  if  the  infant  does  well. 

Stimulation. — Premature  infants  require  stimulation  so  soon  as  born. 
From  two  to  five  drops  of  the  best  brandy  or  whiskey,  in  two  drachms 
of  water,  are  sufficient.  Other  stimuli  are  not  appropriate  and  .seldom 
u.seful. 

Feeding. — The  problem  of  feeding  the  premature  infant  is  especially 
difficult.  The  infant  has  at  first  not  sufficient  strength  to  nurse,  nor 
can  it  be  taken  from  its  receptacle  to  the  mother  without  danger.  It 
is  often  so  feeble  that  it  cannot  wait  for  the  mother's  milk  to  form, 
but  must  be  fed  within  a  few  hours  after  l)irth. 

Where  the  mother's  milk  is  available  and  promptly  and  freely  .secreted 
it  may  be  used  by  extracting  it  with  a  breast  pump,  keeping  it  at  a 
suitable  temperature — 9S°  to  100°  F. — and  feeding  it  to  the  infant. 
This  is  done  by  partly  filling  a  basin  with  hot  water  and  placing  in  the 
basin  a  graduated  glass  already  heated.  The  milk  is  then  puni])ed  from 
the  mother's  breast  into  the  heated  glass  and  taken  immediately  to  the 
infant.  Some  prefer  to  discard  the  glass,  placing  the  ball  of  the  breast 
pump  containing  the  milk  in  hot  water  so  soon  as  the  milk  is  extracted. 
It  is  well  to  thoroughly  examine  breast  milk  in  the.se  ca.ses  to  be  sure 
that  it  contains  sufficient  nourishment  for  the  infant. 

As  a  substitute  for  breast  milk,  the  white  of  egg  in  water,  whey, 
cows'  milk,  well  diluted  untl  predigested  or  modified,  or  chicken-broth  are 
available.  Albumen-water  should  be  prepared  with  the  white  of  an  al)so- 
lutely  fresh  egg  in  S  ounces  of  boiled  water,  and  a  little  salt  may  be  added 
or  it  may  be  slightly  sweetened  with  milk-sugar.  Albumen-water  may 
with  advantage  be  combined  with  barley-water  in  many  cases.  In  using 
cows' milk,  if  tlie  infant  be  feeble,  whey  should  be  made  or  the  diluted  milk 
should  be  partially  pancreatized.  It  will  be  remembered  that  at  certain 
stages  in  this  process  the  milk  may  become  l)itter  and  unpalatable.  It  is 
well  to  begin  with  a  very  moderate  degree  of  heat,  thus  partially  digesting 
the  milk  until  the  infant's  powers  of  assimilation  have  been  tested.  If 
the  infant  for  its  age  be  sturdy  the  physician  may  decide  to  try  milk 
which  is  not  predigested.  Then  modified  milk  of  low  percentage  should 
be  employed,  and  such  a  formula  as  fat  1,  sugar  7,  proteid  0.50  is  useful. 
Townsend's  first  formula'  is  as  follows:  Top  milk  from  quart  bottle, 
1  ounce;  water,  10  ounces;  lime-water,  1  ounce;  sugar  of  milk,  1  ounce. 

'  Archives  of  Pediatrics,  1891,  vol.  viii. 


THE  PREMATURE  INFANT  29 

This  may  be  increased  as  needed.  In  some  cases  freshly  made  chicken- 
broth  skimmed  will  be  better  digested  than  milk.  It  must  not  be 
forgotten  that  the  premature  infant  requires  a  comparatively  large 
quantity  of  water  to  flush  the  kidneys  and  intestines  and  to  assist  in 
starting  the  processes  of  digestion  and  assimilation. 

The  quantity  of  food  and  the  intervals  of  feeding  and  stimulation  are 
of  great  importance.  A  very  feeble  infant  should  be  given  not  more 
than  one  drachm  of  food  in  the  beginning  at  a  feeding,  as  of  Townsend 
formula.  Food  and  stimulant  should  alternate,  the  infant  receiving  one 
of  these  every  hour  or  hour  and  a  half.  As  the  premature  infant  has 
no  idea  of  day  or  night,  judgment  is  requisite  in  not  disturbing  it  too 
frequently  and  yet  in  maintaining  its  nutrition  (Figs.  5  and  6).  If 
the  infant's  color  be  good  and  it  is  resting  quietly  it  may  usually  go  two 
of  three  hours  at  night  without  disturbance.  It  will  soon  form  regular 
habits  and  thus  learn  to  distinguish  night  from  day. 

To  administer  food  to  premature  infants  it  is  usually  best  to  begin 
by  dropping  food  and  stimulant  into  the  mouth  with  a  pipette.  An 
ordinary  medicine  dropper  which  has  been  thoroughly  cleansed  is  con- 
venient. A  long  pipette  having  a  glass  bulb  graduated  is  very  useful. 
Food  and  stimulant  should  be  placed  as  far  back  as  possible  upon  the 
infant's  tongue  so  that  the  reflexes  of  the  pharynx  may  be  excited 
and  deglutition  result.  As  the  infant  gains  in  strength  a  small  rubber 
nipple  may  be  placed  upon  a  small  bottle  and  it  may  suck  this  nipple. 
The  rubber  bulb  of  a  medicine  dropper  pierced  with  several  needle 
holes  often  serves  a  useful  purpose  in  this  feeding.  Towrsend  has 
used  a  glass  tube  with  a  nipple  on  one  end  and  a  rubber  bulb  on  the 
other. 

Few  premature  infants  are  so  weak  that  they  cannot  be  made  to 
swallow  by  patient  but  gentle  manipulation.  Where  such  attempts  are 
unsuccessful,  food  and  stimulant  may  be  introduced  into  the  stomach 
by  gavage.  A  small  soft  catheter  (12  to  16  American  scale),  previously 
warmed,  may  be  passed  into  the  esophagus  through  the  nostrils  or 
directly  through  the  mouth;  a  funnel  being  attached  to  this,  the  desired 
food  and  stimulant  can  be  put  into  the  stomach.  In  all  cases  where 
feeding  is  done  by  gavage  it  is  essential  that  the  infant  should  not 
be  overfed;  and  as  the  amount  of  food  given  seems  so  small,  the  nurse 
often  in  her  zeal  overdoes  it.  The  bov.^el  of  the  premature  infant  is 
rarely  available  as  a  means  of  nutrition.  The  lower  bowel  is  often  partly 
filled  with  meconium,  and  absorption  in  these  cases  is  less  ready  and 
successful  than  in  older  infants  and  children. 

An  auxiliary  method  of  feeding  a  premature  infant  consists  in  the 
use  of  oils  and  fats  by  inunction.  I  have  found  by  experience  that  the 
addition  of  alcohol  or  aromatic  spirit  of  ammonia  to  oil  renders  it 
more  readily  absorbed ;  from  1  to  4  drachms  of  a  mixture  composed  of 
2  parts  olive  oil  and  1  part  alcohol  can  be  introduced  through  the  skin 
by  gentle  massage.  Cod-liver  oil  would  be  especially  valuable  in  some 
cases  if  its  unpleasant  and  abiding  odor  did  not  make  its  use  almost 
impossible.     Inunctions  with  oil   may  be    practised    once  or  twice  in 


30 


DISEASES  AM>   /A./rA'/Z-N   ,>F    THE   SEWBORN 


Fig.  5 


Chart  of  premature  infant. 


THE   PREMATURE  INFANT 
Fig.  6 


31 


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Chart  showing  gain  of  premature  infants  treated  by  incubation,  artificial  feeding,  massage,  and  oil 
inunction  at  the  JefTerson  Maternity  Hospital. 


32  DISEASES  AND   I \. JURIES  OF    THE   SEWBOItS 

twenty-four  hours  and  have  the  additional  advantaj^e  that  the  massage 
which  accompanies  the  inunctions  stimulates  the  infant's  circulation, 
and  its  assimilation.  Such  massage  should  he  done  beneath  a  flannel 
sack  and  without  exposing  the  infant  to  the  external  air. 

The  care  of  the  intestine  in  the  prejnature  infant  is  of  great  importance. 
Meconium  is  fretjuently  retained  and  the  development  of  digestion 
retarded  through  sluggish  action  of  the  intestine.  1  have  found  ilaily 
irrigation  of  the  bowels  with  equal  parts  of  normal  salt  solution  and 
boiled  water  of  especial  value.  This  must  be  not  less  than  ]()()°  F.,and 
should  be  given  with  a  funnel  and  not  with  a  piston  or  valve  syringe. 
It  should  be  done  at  a  regular  time  when  it  is  desirable  to  have  the 
bowels  move.  Occasionally,  it  is  necessary  to  do  this  twice  in  twenty- 
four  hours,  but  care  must  be  taken  not  to  irritate  the  intestinal  mucous 
membrane.  In  cases  where  the  bowel  beconu-s  irritable  salt  solution 
may  be  replaced  by  two  ounces  of  warm  olive  oil.  This  will  encourage 
a  movement  of  the  bowels,  and  a  little  of  the  oil  may  be  retained  to 
advantage. 

In  the  general  care  of  premature  infants,  patience  and  good  sense 
are  of  the  greatest  importance'.  The  premature  infant  should  not  be 
removed  from  the  incubator  until  it  has  attained  the  age  of  normal 
development  and  continues  to  gain  in  weight  and  vigor.  With  some 
mothers  it  is  difficult  to  maintain  a  good  secretion  of  milk  without  the 
stimulus  of  the  infant's  nursing.  Besides  tlie  physical  there  is  to  some 
extent  a  psychical  element  in  the  presence  of  the  infant,  and  when  this 
is  lacking  the  supply  of  milk  may  diminish  or  cease.  Care  should  be 
taken  to  explain  to  the  mother  that  the  enforced  a])sence  of  the  infant 
will  terminate  as  soon  as  possible,  and  she  should  be  encouraged  to  hope 
that  she  will  be  enabled  to  nourish  the  infant  until  it  can  be  applied 
directly  to  the  breast. 

As  the  infant  begins  to  gain  in  weight  its  oil  inunction  may  be  accom- 
panied by  general  massage  combined  with  massage  of  the  intestine,  gently 
given  for  twenty  minutes  or  half  an  hour.  This  develops  the  muscles, 
stimulates  the  circulation,  and  improves  the  infant's  nutrition. 

Absolute  regularity  should  be  observed  in  the  care  of  premature 
infants.  As  they  are  not  yet  sufficiently  developed  to  notice  objects 
about  them,  this  care  is  more  easy  than  in  the  case  of  infants  born  at 
term.  Premature  infants  in  incubators  properly  cared  for  usually  cry 
less  than  full-term  infants,  partly  because  they  are  disturbed  so  little 
and  partly  because  they  are  weaker.  To  care  for  such  an  infant  two 
nurses  are  necessary.  For  several  weeks  the  infant  must  be  constantly 
watched,  and  this  is  almost  impossible  with  but  one  nurse,  even  though 
some  friend  or  relative  assists. 

It  is  not  infrequent  for  premature  infants  to  lose  slightly  or  remain 
stationary  in  development  for  a  short  time  after  birth.  So  long  as  the 
infant's  strength  is  well  maintained,  its  movements  well  digested,  and 
it  is  not  fretful  this  need  occasion  no  alarm.  After  a  slight  pause  it 
will  usually  commence  to  gain.  If,  however,  the  infant  loses  considerably 
or  fails  within  a  reasonable  time  to  gain,  then  some  essential  change  in 


THE  PREMATURE   IX FAX T  33 

its  hygiene  must  be  made.  In  order  to  estimate  the  progress  of  such 
an  infant  it  must  be  weighed  at  regular  and  frequent  intervals.  It 
is  safest  to  weigh  the  incubator  with  its  contents,  and,  knowing  the 
weight  of  the  incubator  and  appendages  without  the  infant,  the  weight 
of  the  child  is  readily  obtained.  If  this  is  impossible,  then  the  infant 
must  be  placed  upon  the  scales,  every  precaution  being  taken  to  avoid 
chill.  A  further  means  of  estimating  the  development  of  a  premature 
infant  consists  in  ascertaining  and  recording  its  length.  Bv  reference 
to  the  chart  (Fig.  6)  it  wall  be  observed  that  a  considerable  increase 
in  length  accompanied  the  gradual  growth  of  the  infant.  It  is  not 
infrequent  for  an  infant  while  growing  in  length  to  remain  stationary 
in  weight.  If  this  be  known  the  failure  of  the  infant  to  gain  in  weight 
is  explained.  If  the  infant  does  well  it  may  leave  the  incubator  perma- 
nently when  it  has  come  to  full  term,  it  being  possible  to  secure  for  it 
adequate  protection  against  cold. 

The  chance  for  a  premature  infant  born  in  the  spring  or  early  autumn 
is  somewhat  better  than  that  of  a  child  bom  in  winter  or  in  the  heat  of 
midsummer.  Premature  infants  are  so  sensitive  that  they  feel  extremes 
in  temperature  even  though  protected  by  an  artificial  environment. 
In  early  summer  the  lid  of  the  incubator  may  be  removed  and  the 
infant  may  be  given  sun  baths  at  a  temperature  as  nearly  as  possible 
that  maintained  by  artificial  heat. 

Prognosis. — A  physician  will  do  wisely  to  withhold  a  prognosis 
regarding  a  premature  infant.  While  many  survive,  others  do  not,  and 
some  fail  without  appreciable  cause.  The  influence  of  infection  must 
not  be  forgotten,  as  it  may  be  the  cause  of  death.  Sudden  death  is  not 
uncommon  in  these  cases  and  nurses  should  be  warned  of  this  fact  in 
undertaking  their  care.  Death  sometimes  occurs  in  con^'ulsions,  but 
most  often  quietly  and  with  so  little  disturbance  that  the  death  of  the 
infant  may  not  be  recognized  for  some  time.  The  state  of  the  heart, 
the  power  of  digestion,  the  action  of  the  lungs,  and  the  influence  of 
infection  all  affect  the  prognosis. 


CHAPTER  IT. 

ASPHYXIA  NEOxNATORUM— ACCIDENTS  TO  THE  UMBILICAL  CORD. 
ASPHYXIA  NEONATORUM. 

By  the  term  asphyxia  we  understand  laek  of  oxy(|;enati()n  of  the  hlood 
with  consecjuent  accuinuhition  of  earbon  dioxide  and  its  poisonous 
effects  upon  the  nerve  centres.  Asphyxia  may  be  intrauterine,  the 
infant  perishin*]^  before  birth,  or  it  may  become  apparent  after  the 
infant  has  been  expelled  from  the  uterus. 

Intrauterine  Asphyxia. — Disease  or  premature  separation  of  the 
placenta,  prolongation  of  the  second  stage  of  labor  from  any  cause, 
or  death  of  the  mother  may  cause  intrauterine  asphyxia. 

Extrauterine  Asphyxia. — This  form  of  asphyxia  of  the  newborn 
commonly  arises  from  occlusion  of  the  umbilical  cord  through  coiling 
or  prolapse  of  the  cord  with  pressure.  Congenital  atelectasis  may  be 
associated  with  asphyxia.  It  sometimes  arises  from  the  inspiration  of 
mucus,  amniotic  liquid,  or  blood.  It  may  also  follow  birth  pressure, 
which  may  produce  cerebral  or  pulmonary  hemorrhage.  Its  effect  on 
the  future  health  of  the  infant  may  thus  be  most  important. 

Symptomatology. — Asphyxia  has  been  divided  into  livid  or  blue 
asphyxia  and  pallid  or  pale  asphyxia.  In  the  livid  or  l)lue  asphyxia 
the  infant's  color  is  dusky  reddish-blue,  the  heart  beat  is  evident,  the 
muscles  are  not  completely  relaxed,  the  pupils  are  not  widely  dilated, 
and  the  reflexes  are,  to  some  extent,  present.  In  pallid  or  pale  asphyxia 
the  infant's  color  is  cadaveric  white,  its  heart  beat  is  imperceptible 
or  very  feeble,  its  pupils  are  widely  dilated,  and  its  reflexes  cannot  be 
excited. 

Treatment. — The  prevention  of  asphyxia  is  entirely  obstetrical. 
Prolonged  labor  with  excessive  birth  pressure  and  injury  to  the  cord 
must  be  avoided.  Late  ligation  of  the  umbilical  cord  indirectly  helps 
to  prevent  asphyxia,  as  it  gives  to  the  infant  a  greater  quantity  of 
oxygenated  blood,  thus  supporting  its  circulation. 

In  the  treatment  of  livid  or  blue  asphyxia  it  must  be  remembered 
that  the  infant  resembles  a  clock  which  has  been  wound,  but  whose 
pendulum  must  be  moved  to  put  the  works  in  motion.  What  is 
needed  in  these  cases  is  to  excite  respiration  by  arousing  the  nervous 
reflexes.  If  the  cord  is  beating  and  the  piiysician  allows  pulsation  to 
cease  spontaneously  before  tying  and  cutting  the  cord,  he  should  then 
determine  the  presence  of  fetal  heart  beats  by  auscultation  or  by  pressing 
with  the  finger-tips  against  the  apex  of  the  heart.  Where  asphyxia  is 
slight,  slapping  the  infant  lightly,  dashing  a  few  drops  of  cold  water  on 
(34) 


ASPHYXIA   NEONATORUM  35 

the  chest,  placing  the  infant  in  a  warm  bath,  and  spraying  a  Httle  cold 
water  upon  the  chest  will  arouse  the  muscles  of  respiration.  If  the 
infant  seems  plethoric  and  oppressed  with  blood  it  may  be  allowed  to 
lose  a  few  drachms  of  blood  from  the  cord. 

If  the  finger  be  dipped  in  whiskey  and  carried  downward  into  the 
fauces  the  infant  will  make  a  sucking  motion  and  may  then  respire. 

Laborde's^  method  of  making  rhythmical  traction  upon  the  tongue  is 
endorsed  by  Rivemont-Desaignes,"  and  also  by  Fronczak,^  who  believes 
that  it  is  safer  than  those  methods  which  expose  the  child  to  rapid  cool- 
ing of  its  body  and  to  the  danger  of  injury  to  the  clavicles.  Laborde, 
in  investigations  made  to  determine  the  length  of  time  after  apparent 
death  in  which  the  reflexes  could  be  excited,  found  this  period  to  be 
three  hours,  and  would  continue  rhythmical  tractions  upon  the  tongue 
for  that  length  of  time. 

Cases  of  livid  asphyxia  require  especial  attention  to  the  cutaneous 
reflexes.  Gentle  friction  while  the  infant's  body  is  immersed  in  a  bath 
of  warm  water  containing  mustard  acts  as  a  powerful  stimulant  to 
respiratory  reflexes.  The  external  application  of  warmth  is  less  necessary 
in  these  than  in  cases  of  pale  asphyxia. 

I  believe  that  in  cases  of  livid  asphyxia  the  right  heart  of  the  infant 
and  the  large  veins  of  the  body  are  overdistended  with  blood.  The 
simple  maneuvre  of  folding  and  unfolding  the  body  of  the  infant, 
proposed  and  described  by  various  observers,  I  have  found  of  great 
value.  After  the  mouth  has  been  thoroughly  cleansed  of  mucus  and 
the  cord  tied  and  cut,  the  infant  is  grasped  with  one  hand  across  the 
back,  the  fingers  resting  upon  the  clavicles;  the  other  hand  grasps  the 
thighs.  Holding  the  infant  with  the  head  down,  the  trunk  is  then 
folded  and  unfolded.  From  ten  to  sixteen  may  be  counted  during  each 
movement  of  the  child's  body.  During  folding  the  abdominal  viscera 
are  carried  up  against  the  diaphragm,  the  diaphragm  is  pushed  upward, 
whatever  air  may  be  in  the  lungs  is  forced  out,  while  the  pressure  brought 
to  bear  upon  the  abdominal  viscera  forces  the  blood  upward  from  the 
abdominal  veins  and  the  pressure  of  the  diaphragm  against  the  heart 
and  lungs  tends  to  promote  the  emptying  of  the  chambers  of  the  heart. 
When  the  infant  is  unfolded  air  may  enter  the  lungs,  the  pressure  on 
the  veins  is  removed,  and  the  conditions  are  more  favorable  for  the 
circulation  of  arterial  blood.  So  successful  in  my  experience  has  this 
sim.ple  maneuvre  been  in  the  treatment  of  asphyxia  that  it  has  largely 
superseded  other  methods  of  treatment.  The  fact  that  it  enables  us  to 
directly  stimulate  the  circulation  by  simple  means  while  furthering  the 
establishment  of  respiration  makes  the  method  especially  valuable, 
even  in  the  treatment  of  pale  asphyxia  where  the  problem  is  more 
difficult,  for  oxygen  must  be  introduced  into  the  blood  and  as  rapidly 
as  possible  to  remove  the  paralyzing  effects  of  the  carbon  dioxide 
already  accumulated.    The  physician  must  not  only  introduce  air  into 

1  Gaz.  des  hSpitaux,  1901,  tome  Ixxiv.  p.  1319. 

2  Annal.  de  GynSc,  1900,  tome  liv.  p.  101.  »  Buffalo  Medical  Journal,  vol.  Iv.  1899, 190O. 


36 


DISI'JASES  AM)   I.\./l'l{Jh'S  OF    THE   SlCWIiORS 


the  child's  chest,  l)ut  \\v  must  stimulate  the  action  of  the  heart,  maintain 
the  warmth  of  the  body,  while  avoiding  injury  to  the  child  hy  any  method 
of  treatment. 

To  secure  the  entrance  of  air  into  the  lungs  artificial  respiration  may 
be  practised.  Marshall  Hall's  metho<l  and  Sylvester's  method  have 
their  advocates  and  have  in  some  cases  proven  efhcient. 


Fig.  7 


Fig.  8 


Schultze's  method:  Infant  going  downward 
for  inspiration. 


Schultze's  method:  Infant  over  operator's 
shoulder  for  expiration. 


Schultze'  descriln's  his  method  as  follows:  While  the  operator  stands 
the  infant  is  grasped  with  both  hands,  Hngers  resting  over  the  scapula? 
and  the  thumbs  upon  the  anterior  surface  of  the  chest  near  the  clavicles 
(Fit's.  7  and  8).  The  infant's  body  is  allowed  to  fall  downward  toward 
the  floor  with  a  swinging  motion.  In  the  same  way  it  is  then  raised  at 
arm's  length  over  the  operator's  head  and  then  with  a  long  swing  it  is 
again  brought  downward  toward  the  floor.  By  the  upward  motion  the 
infant's  body  is  bent  upon  itself,  the  abdominal  viscera  are  crowded 
upward  against  the  diaphragm,  and  expiration  is  promoted.     With  the 

1  Pie  Behandlung.  des  Scbeihtodes  der  Neugeborenen,  Wiener  med.  Presse,  1900,  Bd.  xli.  p.  1518, 


ASPHYXIA    XEOXATORUM  37 

downward  motion  the  abdominal  viscera  gravitate  away  from  the 
diaphragm,  a  vacuum  is  created  in  the  bronchial  tubes,  and  air  rushes 
into  the  lungs.  Abundant  postmortem  examinations  show  that  by  this 
manipulation  air  can  undoubtedly  be  forced  into  the  lungs.  Schultze 
is  aware  that  this  method  exposes  the  child  to  considerable  disturb- 
ance, and  he  advises  Sylvester's  method  with  Pazini's  modification  in 
prematurely  born  infants  who  are  not  of  full  strength  and  development. 
Schultze  argues  that  other  methods  of  treatment  serve  only  to  excite 
reflexes  if  such  be  present,  while  by  his  method  air  is  actually  introduced 
into  the  lungs.  Practure  of  the  clavicle,  as  well  as  other  injuries,  has 
been  observed,  anrl  it  is  also  urged  against  this  method  that  the  child's 
body  becomes  rapidly  cool  and  that  its  use  is  attended  by  considerable 
exposure. 

The  use  of  oxygen  would  theoretically  meet  the  indications  in  pallid 
asphyxia.  It  is  doubtful,  however,  whether  oxygen  can  be  introduced 
into  the  lungs  without  tracheotomy.  Stowe^  reports  the  case  of  a  child, 
severely  asphyxiated  after  birth  in  breech  presentation,  revived  by 
tracheotomy,  the  introduction  of  a  catheter,  and  insufflations  of  air. 

Zangemeister^  introduced  oxygen  through  a  small  tracheal  catheter 
under  feeble  but  constant  pressure.  After  the  lungs  had  become  dis- 
tended he  allowed  thoracic  pressure  to  expel  the  oxygen;  the  result  was 
satisfactory. 

One  of  the  simplest  and  oldest  methods  for  introducing  air  into  the 
chest  has  been  direct  insufflation.  A  handkerchief  was  hastily  thrown 
over  the  mouth  of  the  infant  and  the  physician,  applying  his  mouth, 
breathed  deeply  into  the  infant's  mouth.  Then  by  gentle  pressure  upon 
the  chest  the  air  was  expelled.  This  method  exposes  the  infant  to 
tuberculous  and  other  infection  from  the  mouth  of  the  adult,  while  the 
thoracic  pressure  is  not  always  without  danger.  Others  have  employed 
the  tracheal  catheter  with  the  balloon,  thus  introducing  air  directly  into 
the  larger  bronchial  tubes.  The  direct  insufflation  of  air  is  luit  partially 
satisfactory  and  is  inferior  to  the  introduction  of  oxygen  by  direct 
application  through  the  catheter  or  after  tracheotomy. 

In  treating  cases  of  severe  asphyxia  the  physician  must  keep  in  mind 
that  he  is  dealing  not  only  with  failure  of  respiration,  but  that  the  infant 
is  suffering  from  cardiac  syncope.  Hence,  those  methods  should  be 
employed  which  promote  the  action  of  the  heart.  Such  are  the  use  of 
external  heat,  counterirritation  over  the  precordium,  the  use  of  the 
interrupted  faradic  current,  one  pole  at  the  base  of  the  brain,  the  other 
over  the  heart,  and  the  injection  of  a  half-teaspoonful  of  whiskey  in  a 
half-ounce  of  warm  water  into  the  rectum.  I  have  seen  good  results 
follow  the  administration  of  0.00021  grm.  fg-^  gr.)  of  strychnine  with 
0.000014  grm.  (:^  gr.)  of  atropine  by  h^^odermic  injection.  The 
finger  may  be  dipped  in  whiskey  and  placed  within  the  fauces  as  above 
described.     The  limbs  of  the  infant  may  be  gently  rubbed  from  below 


1  Gaz.  hebdom  de  med.  et  de  chir.,  1902,  p.  10. 

2  Zentralblatt  f.  Gj-niik.,  1902,  Bd.  xxvi.  p.  1161. 


38  DISEASES  AMD  INJURIES  OF   THE   XEWBORN 

upward,  and  normal  salt  solution  may  be  injected  into  the  umbilical  vein 
and  into  the  rectum. 

Although  no  reference  is  found  to  the  use  of  adrenalin  it  would  seem 
reasonable  to  suppose  that  half  a  drachm  of  1 :  10,()()()  solution  might  be 
introduced  through  the  umbilical  vein  to  advantage. 

The  resuscitation  of  an  infant  severely  asphyxiated  may  be  followed 
by  complications.  Thus  inspiration  pneumonia  has  resulted  from  the 
drawing  of  infected  material  into  the  bronchial  tubes.  In  cases  of 
severe  asphyxia  complicated  by  birth  pressure  I  have  seen  pulmonary 
apoplexy  during  the  first  twelve  hours  following  delivery.  Cerebral 
hemorrhage  has  been  found  in  some  cases  of  severe  asphyxia  which 
were  temporarily  revived.  From  manipulation  about  the  mouth  and 
tongue,  wounds  and  infection  have  resulted.  Jacobi  has  observed 
epilepsy  following  resuscitation  from  severe  syncope.  Snow'  re])orts 
two  cases  of  failure  of  respiration  with  cyanosis  of  central  origin.  Cya- 
nosis and  respiratory  failure  have  also  been  observed  early  in  life  after 
dusting  powders  containing  coal-tar  derivatives  have  been  used  to  dry 
the  cord. 

Prognosis. — In  livid  or  blue  asphyxia  with  intelligent  treatment  the 
prognosis  is  good.  It  is  sometimes  impossible  to  decide  positively  that 
an  asphyxiated  infant  is  beyond  resuscitation.  Infants  apparently  dead 
have  been  repeatedly  thrown  into  various  receptacles  antl  have  still 
survived. 

Redfern  and  Newby^  describe  a  case  of  an  asphyxiated  infant  whose 
heart  continued  to  beat  without  respiration  for  two  and  a  half  hours 
after  birth.  Tracheotomy  was  performed  and  breathing  finally  insti- 
tutetl.  Several  hours  after  the  infant  had  been  made  to  breathe  it 
perished  through  a  secondary  asphyxia. 

In  view  of  these  remarkable  resuscitations,  efforts  to  revive  asphyx- 
iated infants  should  be  patient  and  prolonged.  So  long  as  the  faintest 
evidence  of  heart  beat  exists,  efforts  to  revive  the  infant  must  be  con- 
tinued. Especial  attention  must  be  directed  to  maintaining  the  bodily 
heat  of  the  infant  and  to  avoiding  all  violent  manipulation. 

The  mortality  of  asphyxia  in  the  newborn  caimot  be  acciu'ately 
stated.  Cases  differ  greatly  in  severity;  the  circumstances  under  which 
treatment  is  instituted  vary  greatly,  and  the  presence  of  hidden  compli- 
cations which  make  the  case  hopeless  is  often  not  demonstrable  until 
autopsy. 

ACCIDENTS  TO  THE  UMBILICAL  CORD. 

Rupture  of  the  umbilical  cord,  either  preceding  or  following  birth, 
may  destroy  the  life  of  the  infant.  Such  an  accident  is  not  invariably 
fatal,  because  the  vessels  of  the  cord  may  retract  and  serious  bleeding 
may  thus  be  checked.  A  hematoma  may  form  and  hemorrhage  gradu- 
ally cease  through  pressure. 

'  Archives  of  Pediatrics,  October,  1903.  '  British  Medical  Journal,  1901,  vol.  ii.  p  1734. 


ACCIDENTS   TO   THE    UMBILICAL   CORD  39 

Bayer  states  that  in  48  precipitate  births  rupture  of  the  cord  occurred 
in  7,  or  14.5  per  cent. 

Among  those  conditions  which  predispose  to  rupture  of  the  cord 
Bondi^  calls  attention  to  syphilis. 

Hemorrhage. — Primary  bleeding  from  the  cord  is  due  to  violence  or 
slipping  of  the  ligature,  an  accident  to  which  a  large  amount  of  Whar- 
ton's jelly  predisposes  by  making  compression  of  the  vessels  difficult- 
Secondary  bleeding  (spontaneous  or  idiopathic  omphalorrhagia), 
described  by  Runge  as  "  not  a  disease,  but  a  symptom  of  various 
morbid  states,"  is  a  steady  oozing  and  not  a  hemorrhage  from  any 
single  bloodvessel.  Hereditary  hemophilia  is  rare  in  these  cases;  syphilis 
is  apparent  in  some,  but  the  majority  of  them  are  due  to  septic  infec- 
tion. Streptococci,  staphylococci,  and  diplococci  have  been  demon- 
strated at  the  umbilicus  and  in  the  blood  of  the  patients. 

The  onset  of  the  bleeding  may  be  insidious  and  generally  follows  the 
separation  of  the  umbilical  stump,  or  the  general  symptoms  of  septic 
infection  may  precede  it.  By  far  the  greater  number  prove  rapidly 
fatal. 

Treatment. — Under  all  circumstances  the  cord  should  be  tied  firmly 
and  carefully.  It  is  well  to  employ  two  ligatures,  placing  one  a  fi^nger's 
breadth  from  the  umbilicus  and  the  other  near  the  extremity  of  the 
stump.  Pedicle  silk,  or  silk  a  size  larger,  is  safest,  and  fine  silk  may 
be  used  to  tie  the  individual  vessels  if  desired.  All  ligatures  should  be 
thoroughly  sterilized  by  boiling.  Catgut  is  an  unsafe  ligature  for  the 
umbilical  cord  because  of  the  danger  of  slipping,  its  uncertain  sterili- 
zation and  the  risk  of  infecting  it  while  manipulating  the  cord. 

The  cut  end  of  the  cord  should  be  sponged  and  examined  carefully 
to  detect  oozing.  The  vessels  should  be  seen  to  be  empty  and  the  cut 
end  of  the  cord  dry.  The  cord  should  be  dressed  aseptically  in  such  a 
manner  that  it  will  be  disturbed  as  little  as  possible  and  that  traction  upon 
the  knots  of  the  ligature  may  be  avoided.  So  soon  as  possible  a  firm 
but  not  tight  abdominal  binder  should  be  pinned  about  the  abdomen, 
thus  making  pressure  upon  the  umbilicus. 

Where  there  has  been  rupture  of  the  cord  close  to  the  abdominal  wall, 
it  may  be  necessary  to  transfix  the  stump  by  needles  placed  at  right 
angles.  Pressure  may  then  be  made  with  a  figure-of-eight  silk  ligatures. 
If  the  cord  is  thick  and  there  is  a  great  quantity  of  Wharton's  jelly,  it 
is  necessary  to  strip  the  cord  before  ligating  it.  Ruptured  and  soft  cords 
may  be  irrigated  with  normal  salt  solution  and  then  washed  with  alcohol 
before  applying  the  ligature.  The  bleeding  may  sometimes  be  controlled 
by  pressure  applied  with  a  pad  or  by  forceps  allowed  to  remain  twenty- 
four  hours  or  more.  A  compress  may  be  soaked  in  a  solution  of  adrenalin 
— 1 :  1000 — wrapped  firmly  about  the  cord  and  pressure  applied.  Occa- 
sionally it  is  possible  to  isolate  some  bleeding  point,  to  seize  this  with 
the  hemostatic  forceps,  and  apply  a  ligature.  Styptics  are  of  little  or 
no  value  either  in  the  primary  bleeding  or  in  the  later  oozing. 

»  Zentralblatt  f.  Gyiiak.,  1903,  Bd.  Ixix.  p.  223. 


40  DISEASES  AM)   IX.n'UIES   OF    THE   XEU'BOliX 

Septic  Infection. — Septic  infection  of  tlic  imihilical  cord  stiimj)  may 
he  limited  to  the  umhihcal  cicatrix  only;  or,  if  the  infectintj;  organism 
he  the  streptococcus,  the  inflammatory  process  may  spread  to  the  sur- 
rounding skin  and  ceUular  tissue  through  the  lymph  channels,  and 
omphalitis  or  even  erysipelas  result.  Extensive  ulceration  and  gan- 
grene may  follow.  General  infection  with  or  without  thrombosis  and 
inflammation  of  the  vessel  walls  may  occur  if  streptococci  or  staphylo- 
cocci And  entrance  into  the  umbilical  vein  or  arteries.  The  class  of 
infections  where  there  are  no  distinctive  local  signs  frequently  go 
undetected  until  constitutional   svmptoms  su})ervcnc. 

Treatment. — The  enforcement  of  rigid  asepsis  in  the  case  of  the 
umbilicus  is  the  best  prophylaxis.  Where  sepsis  is  already  evident  local 
measures  are  indicated.  Irrigation  with  normal  salt  or  boric  acid 
solution  are  useful.  If  corrosive  sublimate  solutions  are  employed  they 
must  be  well  diluted,  as  infants  are  susceptible  to  their  toxic  effects. 
Preparations  of  peroxide  of  hydrogen  will  search  out  pus  in  the  inter- 
stices around  the  umbilical  ring.  Local  abscesses  are  to  be  treated 
surgically.  It  is  advised  that  these  patients  be  kept  face  downward  .so 
as  to  allow  of  drainage.    Stimulation  by  l)randy  or  whiskey  is  necessary. 

Umbilical  Fungus. — Umbilical  fungus  or  granuloma  is  a  ma.ss  of 
granulations  and  indicates  defective  healing  of  the  umbilicus.  When 
the  granulation  tissue  is  touched  it  may  bleed,  and,  as  the  skin  around 
the  umbilicus  is  kept  moist  by  the  di.scharge  of  serum  or  sero-pus  there 
is  often  an  annoying  eczema. 

Treatment. — After  a  careful  cleaning  with  normal  salt  solution  the 
mass  may  be  ligated,  or,  if  too  small  to  hold  a  ligature,  it  may  be  then 
destroyed  by  one  or  two  applications  of  the  actual  cautery. 


CHAPTEE  III. 

INJURY  AT  BIRTH— INFECTIONS. 

BIRTH  PRESSURE. 

The  most  important  element  in  producing  injury  to  the  cranium  and 
its  contents  during  labor  is  the  continuance  of  birth  pressure,  especially 
where  there  is  a  disproportion  between  the  pelvis  and  the  fetal  head. 

This  pressure  may  cause  such  a  well-known  condition  as  a  cephal- 
hematoma, or  it  may  be  sufficient  to  produce  a  fracture  of  one  or  more 
of  the  cranial  bones.  The  meninges  may  be  torn,  the  brain  lacerated, 
and  extravasations  of  blood  and  cerebrospinal  fluid  may  do  fatal 
injury  to  important  nerve  centres.  Lacerations  of  the  ears,  mouth,  and 
soft  tissues,  with  injuries  to  the  eyes,  may  occur. 

A  study  of  the  mechanism  of  labor  teaches  us  that  it  is  not  the  forceps 
properly  applied,  but  delay  in  labor  with  continuous  birth  pressure 
which  causes  injury.  The  proper  use  of  forceps  undoubtedly  prevents 
injury  in  many  cases,  and  threatened  danger  to  the  fetus  by  continued 
pressure  is  a  valid  indication  for  delivery  by  forceps.  Extreme  effects 
of  pressure  are  shown  in  Figs.  9  and  10. 

CEPHALHEMATOMA. 

Among  the  most  common  of  the  injuries  received  by  the  newborn 
infant  is  that  of  pressure  upon  the  cranium,  which  results  in  the  forma- 
tion of  cephalhematoma  and  also  somewhat  less  frequently  in  injuries  to 
the  sternocleidomastoid  muscle.  Two  factors  combine  in  its  causation : 
defective  ossification  of  the  cranial  bones  at  the  point  where  the 
hemorrhage  develops  and  the  pressure  exerted  on  the  head  at  birth. 

Etiology.— The  resistance  of  the  mother's  tissues,  abnormal  growth  of 
hair  upon  the  child's  head,  premature  rupture  of  the  membranes,  and 
the  use  of  forceps  all  predispose  to  this  condition,  which  has,  however, 
been  observed  in  natural  and  uncomplicated  labors.  Joret  observed 
cephalhematoma  upon  the  occipital  bone  in  children  born  in  breech 
presentation.  Pfeiffer  reports  38  cases  of  cephalhematoma  delivered 
in  breech  presentation  and  15  in  vertex  presentation,  and  among  them 
4  forceps  deliveries;  12  cases  of  breech  presentation  terminated  sponta- 
neously. 

By  internal  hematoma  is  commonly  meant  an  accumulation  of  blood 
beneath  the  internal  pericranium.  The  existence  of  this  condition 
cannot  be  demonstrated  during  life,  but  can  be  inferred  from  the 
existence  of  an  external  hematoma  with  pressure  symptoms. 

(41) 


42 


DISK  ASKS   AXD   IXJUfflKS  OF   THE   NEWBORN 


Ilt'iiiiifoMKi  of  the  stcniDclcidoiiiastoid  iniiscic  occurs  more  frequently 
on  the  rii^lit  side  than  ou  the  left,  and  in  hreech  tlian  in  occi})ital  i)reseu- 
tatious.  It  is  due  to  pressure  and  twisting  of  the  head  at  birth.  The 
hematoma  is  situated  in  the  helly  of  the  muscle  and  is  very  hard. 
It  may  he  acconjjianied  hy  ruj)turc  of  some  of  the  nmsde  fibres  and 
intlanunation  of  the  nuiscle  sheath. 


KiG.  9 


Rupture  of  diaphragm;  intestine  in  thorax.    Anterior  view. 

The  proornosis  is  good,  although  several  weeks  may  pass  before  the 
swelling  has  di.sappeared,  and  a  slight  torticollis  may  "be  present  during 
that  time.     No  treatment  i.s  required  in  tliis  form. 

Cases  of  caput  obstipum  musculare  congenitum,  or  muscular  torti- 
collis, differ  from  simple  hematoma  of  the  sternomastoid  in  that  they 
are  caused  by  intrauterine  malposition  and  pressure,  which  interfere 
with   the  circulation   in   the   muscle  and    result    in   pressure   atrophy. 


INJURY  AT  BIRTH 


43 


Microscopically,  the    muscle    shows    interstitial    myositis.      Operation 
alone  can  improve  or  cure  such  cases. 

Treatment. — In  the  treatment  of  cephalhematoma  and  hematoma  of 
the  sternocleidomastoid  muscle  it  is  of  importance  to  notice  whether  the 
tumor  is  extending  In  cephalhematoma  we  recognize  the  limitation  of 
the  tumor  by  the  distinct  edge  showing  the  margin  of  the  pericranium. 


Fig.  10 


Rupture  of  diaphragm;  intestine  in  thorax.    Posterior  view. 


As  cephalhematoma  is  rarely  double  it  will  usually  be  found  upon  that 
one  area  of  the  cranium  most  exposed  to  pressure.  Ordinarily,  the 
tumor  becomes  sharply  defined,  does  not  extend,  and  does  not  increase 
in  volume.  Absorption  usually  goes  on  gradually,  but  very  slowly, 
owing  to  the  firmer  condition  of  the  tissues  about  the  cranium.  In 
cases  where  the  tissue  is  edematous  and  where  there  has  been  injury 
to  the  soft  parts  with  infection,  a  dressing  kept  moist  with  normal  salt 
solution  or  boric  acid  sohition  should  be  applied.     Should  the  tumor 


44  DlShWSKS  AM)   IXJUiilES   OF    THE   XhlVBOR.W 

increase  rapidly  in  size  or  should  absorption  fail,  the  physician  sliould 
incise  the  tumor  freely,  turn  out  its  clot,  examine  tJiorou<i;hly  for  the 
source  of  fresh  bleeding,  control  such  hemorrliage,  and  pack  the 
cavity  firmly  with  sterile  gauze.  This  should  be  removed  after  twenty- 
four  hours,  the  sac  of  the  clot  again  irrigated,  and  a  similar  packing 
intnxhiced  Aspu'ation  of  the  clot  has  been  advised,  but  tliis  method 
is  inefficient  and  unreliable. 


FRACTURES  OF  THE  CRANIAL  BONES. 

The  most  important  lesions  present  in  cases  where  depressions  of 
the  fetal  cranium  exist  are  fractures.  MacLemion'  describes  nuiltiple 
fractures  of  the  cranial  bones  as  j)resent  in  cases  where  supeiHcial 
examination  showed  depression  of  the  bones  only.  Bernheim"  reports 
a  case  of  delivery  by  forceps  by  which  the  meninges  were  injured  and 
convulsions  followecl.  Tissier^  reports  a  case  of  breech  presentation  in 
which  the  forceps  was  applied  to  the  after-coaiing  head,  followed  by 
the  gradual  development  of  paralysis  of  the  lower  extremities.  The 
nerves  supplying  the  lower  extremities  nmst  have  been  injured  by 
forcible  traction  upon  the  limbs  or  by  pressure  over  the  lower  portion 
of  the  trunk  during  delivery.  Couvelaire^  reports  51  autopsies  upon 
children  dying  with  heatl  injuries  immediately  after  birth;  IS  of 
these  children  were  at  full  term  and  33  were  premature.  Among  the 
premature  infants  there  were  5  cases  of  cerebral  hemorrhage.  Among 
the  IS  who  went  to  full  term  there  were  G  cases  of  spinal  hemorrhage. 

In  reviewing  these  cases  of  direct  injury  to  the  cranium  we  find  that 
the  parietal  bone  is  the  one  most  frecjuently  involved.  Severe  injury 
in  this  region  may  wound  the  branches  of  the  middle  meningeal  artery, 
causing  bleeding  over  the  motor  areas.  The  pressure  of  such  a  clot 
would  lead  to  contracture  and  later  to  atrophy. 


INJURIES  TO  THE  FACE  AND  SOFT  PARTS. 

Injuries  to  the  face  may  also  occur  during  labor  and  may  result  from 
severe  pressure  of  soft  parts  against  the  bones  of  the  pelvis  or  errors  in 
operative  procedure.  Strassmann"'  describes  a  case  of  breech  presenta- 
tion where  the  finger  was  placed  in  the  mouth  to  produce  strong  flexion 
when  the  head  was  born.  The  frenulum  of  tlie  tongue  was  torn  and  free 
bleeding  followed.  In  the  same  journal  Wegscheider^  describes  a  case 
where  the  introduction  of  the  fingers  into  the  mouth  injured  the  gums 
in  the  posterior  portion  of  the  mouth,  causing  severe  bleeding. 

In  some  cases  the  tissues  about  the  orbit  may  rupture  during  labor 
and   suppuration   follow.     In  a  case  under   my  observation  the  infant 

'  Lancet,  1902,  vol.  ii.  p.  632.  2  Progri-s  med.,  1902.  tome  xiv.  p.  179. 

a  Ibid.  *  Ann.  de  gyn.  et  d'obst.,  1903,  tome  lis.  p.  253. 

"  Zeitschr.  f.  Geburtsh.,  1903,  Bd.  xi.  p.  120.  «  ibid. 


IX JURY   AT   BIRTH  45 

developed,  several  days  after  birth,  a  slightly  opaque  tumor  at  the  site 
of  the  bruise,  which,  on  incision,  was  found  to  contain  a  fluid  full  of 
leukoc}i;es  and  microscopically  resembling  pus.  The  opening  was  pre- 
vented from  closing  for  a  few  clays,  the  cavity  irrigated  with  sterile  water, 
and  it  healed  completely  without  injury  to  the  eyeball  or  any  scar. 

Injuries  to  the  Eye. — Jardine^  reports  a  case  of  intracranial  bleeding 
following  labor  in  contracted  pehis  in  which  the  eye  was  injured  and 
hemorrhage  into  the  eye  occurred.  Keratitis  followed  and  ni  twenty- 
four  hours  the  cornea  was  opaque.  It  is  sometimes  difficult  to  decide 
whether  bleeding  from  the  conjunctiva  has  been  caused  by  injury  at 
birth  or  by  some  accident  or  manipulation.  Wiener^  reports  a  case  of 
fatal  hemorrhage  from  both  conjunctivae  seven  days  after  labor.  In 
the  absence  of  other  causes  he  ascribes  this  to  irritation  produced  by 
the  emplo}Tiient  of  Crede's  method  to  prevent  ophthalmia.  Terrien^ 
describes  wounds  occurring  in  the  eyes  during  laljor  by  long-continued 
pressure,  by  the  use  of  forceps  or  by  unskilful  manipulation  with  the 
hands.  As  a  result  of  such  injuries  paralysis  of  the  ocular  muscles  may 
occur,  the  lids  may  be  paralyzed,  and  in  deep  wounds  lesions  may  extend 
even  to  the  eyeball.  In  some  cases  where  the  eyes  themselves  are  not 
directly  pressed  upon,  severe  and  continued  pressure  on  the  cranium 
may  cause  hemorrhage  into  the  retina  and  choroid. 

PauP  examined  the  eye-ground  in  200  infants  recently  born.  In  those 
born  after  labor  with  contracted  pelvis  there  was  some  hemorrhage  in 
the  retina  in  50  per  cent. ;  in  children  prematurely  born  spontaneously, 
in  40  per  cent.  In  long  and  complicated  labors  of  all  kinds  there  was 
retinal  hemorrhage  in  40  per  cent.  In  apparently  normal  cases  of 
spontaneous  birth  there  was  retinal  hemorrhage  of  greater  or  less 
degree  in  20  per  cent. 

In  injuries  to  the  eyes,  if  the  eyeball  be  dislocated,  it  should  be  replaced 
as  soon  as  possiVjle  and  kept  bandaged  with  gauze  pads  saturated  with 
boric  acid  solution  or  sterile  water.  An  oculist  should  have  an  oppor- 
tunity to  advise  regarding  operative  interference  in  all  such  injuries. 

Injuries  to  the  Ear. — The  ear  of  the  child  maybe  torn  from  the  head, 
or  in  cases  where  the  base  of  the  cranium  is  extensively  fractured  the 
temporal  bone  may  be  crushed  and  the  auditory  canal  and  tympanum 
lacerated. 

In  injuries  to  the  ear  if  a  portion  of  the  ear  be  lacerated  the  tear 
should  be  immediately  closed  -with  fine  sterile  catgut.  It  must  be 
remembered  that  in  injuries  to  the  ear  a  physician  must  always  suspect 
damage  to  the  mastoid  region.  Should  infection  occur,  mastoid  sup- 
puration will  be  threatened.  In  these  cases  the  mastoid  area  should  be 
opened  early  and  drainage  secured. 

Symptomatology. — ^The  immediate  result  of  cranial  traumatism  at 
birth  may  be  stupor  or  partial  coma,  the  infant  frequently  l^^ng  quietly 
without  cr}dng,  or  in  severe  cases  giving  utterance  to  an  irregular  and 

1  Journal  of  Obstetrics  of  the  British  Empire,  June,  1903,  vol.  iv. 

-  St.  Louis  Medical  Review,  April  25, 1903.  ^  Arch,  d'ophtal.,  1903,  tome  iv, 

*  Inaug.  Diss.,  Halle,  1900, 


46  DISEASES   AM)   IXJlh'IES  OF    THE   .\E\yjiUh'.\ 

sharp  cry.  In  cases  where  severe  internal  hemorrhage  oeeiirs,  symptoms 
of  intracranial  pressnre  will  rapidly  develop,  with  syncope  and  fatal 
issue.  In  cases  of  lesser  injin-y  the  infant  may  rally  innnediately  from 
the  traumatism,  and  should  it  be  able  to  nurse  it  may  survive  indefinitely. 
In  these  cases  the  secondary  results  of  birth  pressure  will  be  observed 
later  in  contractures  or  atrophy  of  muscles  with  corresponding  deformity. 
'I'here  will  be  alterations  in  sensation,  in  temperature,  and  in  nutrition 
of  the  skin  and  neighboring  tissues.  (See  Diseases  of  the  Nervous 
System.) 

The  immediate  symptoms  accompanying  injuries  to  the  head  in  new- 
l)orn  infants  differ  somewhat  from  those  produced  by  similar  lesions  in  the 
adult.  In  the  latter  unconsciousness  is  the  termination  and  may  be  the 
result  of  head  injury.  In  the  infant  consciousness  is  scarcely  developed 
at  birth,  and  the  physician  cannot  expect  the  same  pronounced  symptom 
which  he  would  observe  in  the  adult.  In  the  adult  it  is  unusual  for  the 
patient  receiving  a  head  injury  to  moan  or  cry.  In  the  infant  one  of 
the  most  significant  features  of  injury  to  the  cranium  or  its  contents 
is  a  peculiar,  sharp,  and  almost  incessant  cry,  very  different  from  the 
crooning  or  grunting  of  the  uninjured  healthy  infant.  In  the  infant 
having  a  head  injury  at  birth  the  breathing  is  seldom  established 
normally.  I'sually,  the  respiratory  rate  is  increased  and  the  breathing  is 
manifestly  difficult,  \Vhere  severe  injury  with  intracranial  hemorrhage  is 
present  the  infant  may  be  so  overcome  that  the  cry  is  feeble.  Attacks  of 
spasmodic  breathing  often  accompany  or  follow  the  cry,  with  asphyxia  in 
greater  or  less  d(>grce.  The  infant  is  often  thirsty,  taking  water  greedily 
or  nursing  with  uncommon  vigor.  It  is  restless,  with  twitchings  or  con- 
vulsive movements  of  the  limbs.  The  pupils  may  be  widely  dilated  or 
contracted.  The  temperature  may  at  first  be  subnormal,  afterward 
rising  considerably  above  the  average;  hence,  the  necessity  for  recording 
the  temperature  in  all  newl)orn  infants.  In  some  cases  convulsions 
occur,  usually  developing  some  iiours  after  l)irth  and  accompanied  by 
asphyxia.  Attacks  of  syncope  with  threatened  failure  of  respiration 
and  pulse  arc  common,  and  in  one  of  them  the  child  may  die.  Death 
is  often  without  warning  and  fre(iuently  without  convulsive  movements, 
th(>  phenomenon  of  life  ceasing  almost  instantly. 

Treatment. — The  treatment  of  injuries  to  the  head  occurring  during 
labor  should  embrace  especially  a  thorough  prophylaxis,  which  is 
entirely  obstetrical. 

In  all  cases  where  such  injuries  are  suspected  the  infant  shoidd  he 
carefully  examined  as  soon  as  possible  after  birth.  The  nostrils  and 
mouth  should  be  thoroughly  cleansed  to  pr(>vent  asphyxia  from  the 
presence  of  mucus  or  other  inspired  material.  All  wounded  surfaces 
should  be  thoroughly  washed  and  kept  protected  by  wet  dressings. 
The  scalp  should  be  gently  cleansed  with  sterile  water  and  the  cranium 
examined  for  evidences  of  depression.  Should  marked  depression 
without  evident  fracture  or  distinct  fracture  and  depression  be  observed, 
the  physician  must  seriously  consider  the  question  of  operation  and  a 
surgeon   should   be  called  in  consultation.      It    must    be   remembered 


INJURY   AT  BIRTH  47 

that  the  cranial  bones  of  the  infant  are  very  thin  and  yielding,  that 
the  tissues  readily  undergo  necrosis,  and,  hence,  that  long  incisions  in 
the  scalp  or  periosteum  or  meninges  should  if  possible  be  avoided. 
If  possible,  depressed  bone  should  be  raised  subcutaneously  by  intro- 
ducing a  blunt  instrument  through  a  small  opening  and  cautiously 
raising  the  bone.  If  the  fracture  is  in  such  a  location  that  an  important 
vessel  is  probably  torn,  then  sufficient  incision  should  be  made  over  this 
point  to  give  access  to  the  vessel.  The  meningeal  arteries  are  those  most 
frequently  injured  and  most  often  requiring  ligation.  It  is  well  to  drain 
such  wounds  for  a  short  time  to  prevent  the  formation  of  a  clot  which 
may  cause  injurious  pressure.  ^Vhile  extensive  operations  cannot  be 
borne  by  the  newborn  infant,  it  has  been  possible  in  a  considerable 
number  of  cases  to  relieve  pressure  s}-mptoms  and  to  bring  about  the 
recovery  of  the  infant  by  appropriate  operation. 

Ross^  reports  a  successful  operation  twenty  days  after  birth. 


PARALYSIS  FOLLOWING  BIRTH. 

Facial  Paralysis. — The  most  frecjuent  paralysis  following  labor  is 
that  of  the  facial  nerve.  This  is  seen  most  often  in  cases  of  difficult 
birth  where  pelvic  contraction,  excessive  size  of  the  child,  or  difficult 
instrumental  delivery  is  present,  and  it  has  been  seen  in  Cesarean  section 
by  Yogel,^  who  reports  a  case. 

Facial  paralysis  in  the  infant  may  also  be  congenital  and  result  in 
no  degree  from  parturition  itself.  Franceschetti^  reports  28  cases  of 
congenital  facial  paralysis  in  newborn  infants  caused  by  some  mal- 
formation of  the  bones  of  the  cranium  resulting  in  pressure  upon  the 
nerve  at  its  point  of  exit  or  some  abnormality  of  the  nerve  itself.  Heller* 
describes  similar  cases.  Kcster''  reports  the  case  of  2  infants  born 
of  the  same  mother  suffering  from  facial  paralysis  with  total  aplasia  of 
the  ganglion  of  the  facial  nerve.  JNIace"  divides  paralyses  following 
birth  into  traumatic  and  spontaneous.  Other  causes  are  amniotic  adhe- 
sions compressing  the  nerve  trunk  or  defective  development  in  the  facial 
nucleus.  Libin,^  in  330.3  births  at  the  Charite,  sav;  32  cases  of  facial 
paralysis,  and  of  these  2.5  were  delivered  by  the  use  of  forceps  and  7 
occurred  in  spontaneous  labor.  The  whole  number  of  forceps  deliveries 
was  1063.  In  3  cases  the  facial  paralysis  was  permanent.  He  ascribes 
this  accident  not  so  much  to  pressure  by  forceps  as  by  the  bones  of  the 
pelvis  and  contracted  pelvis;  meningeal  bleeding;  extravasation  of  blood 
in  the  region  of  the  amniotic  adhesions  during  the  development  of  the 
face,  and  pressure  of  the  child's  cheek  against  the  bones  of  the  pelvis. 
Hemorrhages  into  the  cerebral   cortex,  into   the   nucleus  of  the  facial 

1  British  Medical  Journal,  1904,  vol.  i.  p.  880. 

=  Z€itschr.  f.  Geburtshulf.  und  Gyn.,  1902,  Band  xlviii.  p.  474. 

3  These  de  Bordeaux,  1903.  42.  4  The."^  de  Paris,  1903,  1361. 

5  Deutsch.  med.  Woch.,  1902,  Band  xxviii.  p.  60.  6  Obstetrique,  1901,  tome  vi.  p.  517. 

'  Inaug.  Diss.,  Beriin,  1901. 


48 


DISEASES   AM)   LX./i'RIKS   OF    THE   NEWBORN 


ncrvr  or  iirrvi"  trunk,  and  j)r(\ssiirc'  Uy  l)()iu'  and  soft  tis.siR'  arc  the 
usual  causi's. 

In  addition  to  facial  paralysis  the  infant  may  develop  strabismus  or 
other  ocular  symptoms,  as  described  by  Nettleship.' 

Brachial  Paralysis. — Next  to  facial  j)aralysis  injuries  to  the  brachial 
j)l('\us  may  result  in  ])aresis  or  paralysis  of  the  upper  extremities. 
Thorburne  found  injury  to  the  brachial  plexus  in  1  in  2()()()  cases; 
50  per  cent,  of  these  were  in  breech  presentation.  The  nerves  most 
commonly  atlected  were  from  the  fourtli  to  the  sixth  cervical  nerves, 

Fio.  11 


Duchennc's  paralysis  of  right  arm  before  operation. 

inclusive.  Schiiller  rej)orts  'A  cases  of  brachial  palsy,  1  occurring  in 
breech  presentation.  The  roots  of  the  sixth  and  .seventh  cervical  nerves 
were  implicated  in  .some  cases,  and  in  1  the  sternocleidomastoid 
muscle  was  also  shortened.  Parry'  describes  2  cases  of  paralysis  of  the 
arm  and  hand  foll()wiii<,'  dehvery.  In  these  the  fifth,  sixth,  and  .seventh 
cervical  nerves  were  at  fault.  One  of  these  cases  was  complicated  by 
torticollis  and  rupture  of  the  fibres  of  the  .sternocleidoma.stoid  mu.scle. 
There  may  be  pressure  on  the  nerves  by  a  fracture  and  the  resultant  callus. 


•  Archiv  f.  Augenheilkunde,  1903,  Band  xlvi.  Heft  4. 
>  Wiener  klin.  Woch.,  1902,  Band  xvi.  p.  937. 


J  Lancet,  1902,  vol.  ii.  p.  1631. 


INJURY  AT  BIRTH 


49 


In  a  case  reported  by  Riihle*  the  infant  had  paralysis  of  the  right 
arm.  Under  treatment  with  galvanism  recovery  followed  in  five  months 
after  birth.  In  many  of  these  cases  separation  of  the  epiphyses  is 
suspected. 

Stalper^  draws  attention  to  the  fact  that  in  many  of  these  cases  strong 
lateral  traction  is  made  upon  the  plexus,  although  an  actual  laceration 
of  the  nerves  is  of  the  greatest  rarity.  The  tissues  surrounding  the 
nerves  may  be  lacerated,  and  as  a  result  a  callus  of  connective  tissue 
develops  which  compresses  the  nerve  trunks.     That  extensive  lesions 

Fig.  12 


jDuchenne's  paralysis  of  right  arm  after  operation  ;  shows  recovery  of  abduction  of  arm  and 

flexion  of  forearm. 


may  follow  injuries  to  the  brachial  plexus  is  illustrated  in  a  case  described 
by  Philippe  and  Cestan  f  in  this  patient  bilateral  monoplegia  and  mus- 
cular atrophy  of  the  arms  developed,  with  spastic  symptoms  and  increase 
in  tendon  reflexes  without  diminution  of  sensibility.  The  lesions  were 
those  of  the  middle  portion  of  the  brachial  plexus,  and  included  the 
anterior  as  well  as  the  posterior  roots  of  the  plexus.  In  long-continued 
spontaneous  labor  paralysis  of  one  or  both  arms  may  result  from  cerebral 

1  Beitrage  zu  Geburtshiilfe  und  Gyn.,  1903,  Band  viii.  p.  64. 
2Monatsch.  f.  Geburtshiilfe  und  Gyn.,  1901,  Band  xiv.  p.  49. 
3  Gaz.  des  hopitaux,  1900,  tome  Ixxiii.  p.  785- 


50 


DISEASES  AM)   IXJi'h'lES  OF    THE   XEWliORX 


apoplexy,  as  has  Ihhii  mentioned.  Martin'  describes  sneh  a  ease, showing 
after  hirth  inward  rotation  of  l)otli  Innneri,  supination  of  the  forearm, 
ri<nditv  of  the  nniseles,  and  increased  reHexes.  The  injnry  present  was 
an  apoi)lexy  in  the  motor  centres  which  followed  a  short  asphyxia. 

Treatment. — Injuries  to  the  brachial  plexus  have  been  usually  treated 
by  splints  and  by  massage  and  the  galvanic  current.  Care  is  necessary 
to  keep  up  the  warmth  of  the  extremity  supj)lied  by  the  injured  nerve. 
A  splint  may  be  needed  if  there  is  contraction.  ^Vhere  contractions  have 
resulted  Kemiedy^  has  obtained  good  results  by  cutting  tlown  upon  the 
injured  nerve  trunks,  loosening  adhesions,  excising  the  injured  atid 
thickened  portions  of  the  trunk,  and  bringing  the  cut  ends  together 
with  fine  catgut.  Of  course,  this  cannot  be  don(>  until  some  time  after 
birth  (Figs.  11  and  12).  Very  recently  Clark,  Taylor,  and  Prout'  have 
done  valuable  work  on  these  lines. 


FRACTURES  OF  THE  EXTREMITIES. 

Fractures  of  the  extremities  are  not  infrequent  in  .severe  and  cotnpli- 
cated  labors.  Mnus,'  in  1200  cases  of  vertex  presentation,  found 
eighteen  fractures  of  the  clavicle,  and  in  another  series  of  500  labors 


Fig.  13 


Fracture  of  humerus  in  difficult  version. 


four,  making  an  average  fre(|nency  of  1.3  per  cent.  The  anterior  clavicle 
was  most  frecjuently  wounded  in  the  j)roportion  of  15  to  3.  The  site  of 
fracture  was  usually  the  middle  third. 

Uagnvaldson'  oljserved  fracture  of  the  humerus  in  spontaneous  labor, 
vertex  presentation,  when  the  arm  prolap.sed  beside  the  head  (Fig.  13). 


'  Lancet,  1900.  vol.  i.  p.  541. 

2  British  Medical  Journal.  1903.  vol.  i.  p.  2ftS,  and  1904,  Xo  2286.  p.  1065. 
«  American  Journal  of  the  Medical  Sciences,  October,  1905,  p.  670. 
«  Central blatt  f.  Gynak.,  1903,  Band  xxvii.  p.  689. 


6  Ibid.,  p.  1208. 


INJURY   AT  BIRTH 


51 


In  some  cases  congenital  fragility  of  the  bones  is  an  important  element 
in  the  production  of  fractures.  Officer^  observed  two  such  cases  in  the 
same  family,  one  of  whom  had  fracture  of  both  femora  and  the  other 
fracture  of  the  arm  at  birth. 

In  a  most  important  contribution  to  the  subject  of  fractures  in  the 
newborn  by  Sperling,^  he  found  by  microscopic  .r-ray  studies  that  many 
supposed  fractures  of  fetal  bones  could  not  be  referred  to  traumatism  at 
birth,  but  that  they  result  from  abnormal  development  in  the  embryo. 
x\mniotic  adhesions  are  a  frequent  factor.  These  develop  in  the  first 
or  second  month  of  embryonal  life.  They  produce  no  callus,  but  an 
infiltration  of  small  cells  with  periostitis.  A  skiagraph  shows  no  bend- 
ing of  the  bone  in  callus.     Lesions  in  the  skin  at  these  points  do  not 


Fig. 14 


Congenital  deformity  of  the  hip-joint. 

extend  through  the  entire  integimient,  but  are  superficial  only  and  are 
also  referred  to  amniotic  lesions.  Defects  in  the  development  of  the 
fibula  and  in  the  digits  were  also  found  in  these  cases.  In  60  per  cent, 
of  cases  supposed  to  be  intrauterine  fractures  these  defects  were  present. 
There  are  no  signs  in  these  cases  of  previous  traumatism. 

Fractures  of  the  femur  are  rare  during  childbirth.  Injury  to  the  ankle- 
joints  may  result  from  forcible  traction  upon  the  feet,  from  the  slipping 
of  the  hand  encased  in  rubber  doves. 


1  Intercolonial  Medical  Journal  of  Australasia.  October  20,  1902,  vol.  vii. 

2  Centralblatt  f.  Gynak.,  1902,  Band  xxvi.  p.  1134. 


52 


DISEASES  AM)   IXJUIilES  OF    THE   XEWBORN 


ConjToiiital  dislocation  of  tiic  liij)-joiiits  must  not  l>e  mistaken  for 
traumatic  dislocation.  The  latter  must  he  of  excessive  rarity,  as  an 
examination  of  recent  literature  fails  to  Hud  it  recorded.    Whitman  states 


Fig.  15 


/yyA>, 


Fracliire  of  both  clavicles  ;  mo<lc  of  dressing;   recovery. 

that  congenital  dislocation,  "in  some  cases  at  least,  is  at  birth  a  .sublux- 
ation only,  that  becomes  complete  through  muscular  action." 

Fracture  of  the  ribs,  sternum,  or  peKis  in  the  newborn  may  also  occur. 


< 


<D 

en 


PLATE  II. 


Fetal  Skeleton,  showing  Failure  of  Ossification  in  Lower 

Extremity. 


INFECTIONS  OF   THE  NEWBORN  53 

Diagnosis. — In  diagnosticating  fractures  of  the  extremities,  ribs,  ster- 
num or  pelvic  bones  the  physician  must  remember  that  the  epiphysis  of  a 
long  bone  may  readily  be  separated  from  the  shaft  of  the  bone  in  the 
infant.  Fractures  are  often  green  stick  in  variety  and  crepitus  will  be 
obtained  indistinctly.  The  joints  of  the  infant  are  so  loose  that  they 
may  be  considerably  stretched  during  delivery  v^ithout  actual  trauma. 

In  an  uncertain  case  of  injury  an  x-ray  photograph  should  be  secured. 
(See  Plates  I.  and  II.) 

Treatment. — ^The  treatment  of  fracture  of  the  clavicle  in  infants 
consists  in  keeping  the  infant  as  much  as  possible  in  a  recumbent 
posture.  It  is  difficult  to  apply  a  retention  bandage  or  dressing  to  a 
newborn  infant  and  equally  difficult  to  keep  the  infant  constantly  recum- 
bent. vSome  such  device  as  that  employed  habitually  by  the  Indian 
mother,  who  puts  her  infant  upon  a  board  and  fastens  it  there  with 
cloth  or  broad  bandages,  is  appropriate  in  these  cases. 

In  a  case  of  double  fracture  of  the  clavicle  occurring  in  the  practice 
of  Dr.  Geo.  A.  Ulrich,  of  Philadelphia,  the  infant  was  put  on  a  board 
twenty-four  inches  long  and  seven  inches  wide,  carefully  padded  with 
a  narrow  board  placed  across  it  one-quarter  of  the  distance  from  the 
top  and  firmly  fastened.  The  infant's  arms  were  carried  upward, 
and  were  firmly  bandaged  to  the  sides,  absorbent  cotton  being  inserted 
so  that  the  skin  surfaces  did  not  come  in  contact.  A  small,  firm  pad  was 
placed  between  the  shoulders  and  a  similar  pad  over  each  clavicle.  The 
splint  was  allowed  to  remain  for  eighteen  days,  when  it  v/as  removed 
and  the  clavicles  found  to  be  completely  united,  with  no  perceptible 
deformity  (Fig.  15). 

In  treating  fractures  of  the  long  bones  in  the  newborn  care  must  be 
taken  to  avoid  undue  pressure  in  applying  splints.  Soft  material  which 
can  be  moulded  to  the  limb  of  the  infant  should  be  selected.  Ordinary 
pasteboard  dipped  in  hot  water  may  be  softened  and  applied  to  the  limb 
and  then  allowed  to  become  partially  stiff  and  moulded  over  the  frac- 
ture. Spongiopiline  and  other  flexible  material  may  be  used.  The 
splints  should  be  carefully  padded  and  the  padding  may  be  kept  in 
place  on  the  splint  by  covering  it  with  gauze  and  stitching  the  gauze 
over  the  splint.  The  splint  should  be  retained  in  position  by  bandages 
of  gauze  or  flannel,  which  are  more  elastic  than  muslin  bandages.  So 
soon  as  a  firm  callus  lias  formed  massage  is  of  especial  value  in  these 
cases.  By  this  adhesions  are  prevented,  the  muscles  are  developed,  and 
absorption  of  the  callus  is  promoted. 

Compound  fractures  are  of  the  greatest  rarity  and  should  be  treated 
by  drainage  with  wicks  of  sterile  gauze  and  by  thorough  asepsis. 


INFECTIONS  OF  THE  NEWBORN. 

The  infections  of  the  newborn  may  be  antenatal,  those  happening 
during  birth  and  those  arising  immediately  after  birth  (postnatal). 
Syphilis  is  the  most  frequent  of  antenatal  infections.     Tuberculosis 


54 


DISEASES   AM)   IXJCh'/ES  OF   THE   XEWBORX 


is  rare,  only  seven  authentie  cases  being  on  reeortl.  Gonorrhea  may 
occur  as  a  prenatal  infection  in  cases  where  the  membranes  were  rup- 
tured soini-  time  before  delivery,  or  where  a  placentitis  involved  the 
amnion  and  gonococci  thus  found  their  way  into  the  anmiotic  sac.  In 
this  way  may  Ik*  explained  the  cases  of  ophthalmia  occurring  in  infants 
ilelivered  by  Cesarean  section.  \'ariola,  scarlatina,  measles,  cholera, 
tvphoid  fever,  yellow  fever,  relapsing  fever,  pneumonia,  influenza, 
(•erel)rosj)inal  meningitis,  and  malaria  have  all  occurred  in  the  fetus 
or  newborn  infant  as  a  result  of  antenatal  infection  from  the  mother. 

Maternal  toxemia  during  pregnancy  may  be  transmitted  to  the  infant, 
with  a  fatal  result  within  the  uterus  or  soon  after  the  infant  is  born. 
In  one  of  my  cases  the  mother  became  acutely  toxemic  before  the  birth 
of  her  infant,  who  perished  eleven  days  after  birth,  with  high  temperature 


Fi.;   If, 


*'^ 


■■3-'*  ,*'.'.-:•  r     \     .       ■  -■     ,. '-f '-.''■■  (S.-c  1 


Lesion  in  the  lung  a.';  observed  in  prenatal  infection;    A,  wall  of  bronchus:  B.  air  vesicles  : 
C,  connective  tissue  and  intervesicular  structure. 

anrl  multiple  hemorrhages  from  all  mucous  surfaces.  At  autopsy  the 
umbiheus  apj)eare<l  free  from  infection  or  inflammation.  The  abdomen 
contained  blood-stained  serous  fluid,  the  mesenteric  blood ve.s.sels  were 
empty,  and  the  lymph  nodes  were  swollen.  The  pleural  membranes  were 
dry  and  .sticky,  the  blood  fluid  and  dark,  the  lungs  dark  red  in  color, 
the  suprarenal  capsules  contained  fluid  ]>lood,the  kidnevs  were  engorged, 
and  multij)le  hemorrhages  were  present  in  the  .stomach  and  inte.st'ine! 
At  the  time  of  the  infant's  death  its  hemoglobin  was  110  per  cent., 
hemoglobin  crystallizing  upon  the  .slide.  The  red  corpu.scles  were  greatly 
di.storted  and  the  eosinophile  cells  were  much  increased.  The  infant's 
feces  contained  bacillus  coli  communis  and  staphylococcus  pyogenes 
aureus.  The  difl"erent  organs  showed  non-infective  periarteritis  in  all 
the  small  vessels.    I  have  seen  .similar  lesions  in  an  infant  born  just  after 


INFECTIONS  OF   THE  NEWBORN 


55 


the  death  of  the  mother  from  eclampsia,  the  infant  surviving  the  mother 
for  some  days  and  dying  with  symptoms  of  acute  toxemia  (Figs.  16,  17, 
and  18j. 

Treatment. — Practically  the  physician  must  recognize  conditions  accom- 
panied by  passive  hemorrhage  without  anatomical  lesion  in  new-born 
infants  as  cases  of  infection.  As  pathogenic  bacteria  are  found  in  the 
intestine  of  the  infant  in  many  of  these  cases,  the  most  valuable  method 
of  treatment  in  my  experience  has  been  the  thorough  irrigation  of  the 
intestine  with  sterile  salt  solution.  The  infant's  food  must  be  carefully 
chosen  and  suitable  stimulation  given.  No  other  method  of  treatment  has 
been  of  especial  value.  The  treatment  of  syphilitic  and  gonococcic  infec- 
tions will  be  mentioned  later. 


Fig.  17 


Intranatal  and  postnatal  infections  may  occur  by  means  of  the 
vaginal  secretion  of  the  mother,  the  hands  of  the  physician  or  nurse, 
dressings,  instruments,  clothes,  the  air  of  the  room,  water  used  for 
bathing  or  drinking  purposes,  and  the  infant's  food,  whether  human 
milk  or  cow-s'  milk.  Finally,  cases  of  autoinfection  by  means  of  the 
infant's  own  secretions  (nasal,  buccal,  vaginalj  have  been  reported. 


56 


DISEASES  AXD  IXJURIES  OF  THE   NEWBORN 


The  bacteria  which  has  been  isolateil  from  cases  of  general  infection 
of  the  newborn  are:  the  streptococcus,  stapliylococcus  albus,  citreus,  and 
aureus;  pneuniococcus,  an  organism  closely  resembling  it,  pneumo- 
bacillus  of  Friedliinder,  bacillus  coli  communis,  Gartner's  bacillus, 
bacillus  proteus  vulgaris,  and  bacillus  pyocyjineus.  The  gonococcus, 
diphtheria  bacillus,  and  tetanus  bacillus  ha\'e  been  found  locally  at  the 
point  of  infection. 

The  most  common  point  of  entrance  is  the  umbilicus,  although  the 
skin,  the  mucous  membrane  of  the  respiratory,  digestive,  and  genito- 


FiG.  18 


^^^ 


Lesion  in  artery;  yirenatal  infection. 

urinary  tracts,  the  conjunctiva  and  the  ear  may  all  act  as  starting 
points  for  local  or  general  infections.  The  mammary  glands  may  be 
infected  as  the  result  of  squeezing  or  rubbing. 

Staphylococci  (albus  and  aureus)  have  been  found  in  woman's  milk 
from  an  apparently  normal  breast;  in  cases  of  irritation  or  fissure  of 
the  nipples  these  organisms  are  almost  invariably  present,  and 
streptococci  have  been  found  as  well. 

Symptomatology. — The  symptoms  of  septic  infection  in  the  newborn 
naturally  manifest  themselves  in  the  organ  where  infection  originates. 


INFECTIONS  OF   THE  NEWBORN  57 

Infection  of  the  skin  may  result  in  erythema,  pemphigoid  eruptions, 
furuncles,  abscesses,  ulceration,  and  petechial  hemorrhages.  If  the 
mouth  be  the  site  of  infection,  there  may  be  catarrhal  stomatitis, 
thrush,  superficial  or  deep  ulceration,  pseudomembranous  inflamma- 
tion, and  even  gangrene.  Gonorrheal  ulcers  are  occasionally  seen  in 
the  mouth.  Smaller  or  larger  ecchymoses  on  the  palate  and  inside  of 
the  cheek  are  common.     The  cervical  lymph  ncdes  may  be  swollen. 

Infection  of  the  respiratory  tract  results  in  nasal  catarrh,  laryngitis, 
bronchitis,  or  pneumonia. 

Anorexia,  vomiting,  diarrhea,  and  hemorrhage  from  the  stomach  or 
intestines  follow  infection  of  the  gastrointestinal  tract.  While  such 
infection  may  undoubtedly  be  primary  and  prove  the  starting  point  of 
a  general  sepsis,  the  majority  of  cases  of  gastrointestinal  infection  are 
secondary  to  the  entrance  of  bacteria  at  some  other  point. 

Infection  of  the  vagina  may  be  followed  by  mild  or  severe  inflamma- 
tion, and  by  gangrene. 

The  urine  may  be  diminished,  and  hemoglobin,  blood  cells,  pus,  and 
casts  may  be  found  in  it. 

Pus  may  develop  in  one  or  more  joints.  There  may  be  progressive 
loss  of  weight,  and  the  influence  of  toxins  on  the  nervous  system  may 
cause  restlessness  or  coma,  local  or  general  convulsions,  irregular  pulse 
and  irregular  respiration.  The  temperature  throughout  the  entire 
course  may  not  be  elevated,  or  it  may  be  very  high. 

Ophthalmia. — If  the  eyes  have  been  infected  the  lesions  will  differ 
with  the  variety  of  the  infecting  germ  and  its  virulence.  ZabeP  examined 
33  cases  of  acute  typical  ophthalmia,  finding  the  gonococcus  present  in 
19.  The  pneumococcus,  staphylococci,  and  bacilli  were  found,  and  in 
some  cases  no  pathogenic  bacteria  were  present.  liesions  of  the  cornea 
do  not  prove  gonorrheal  infection,  for  in  6  cases  without  the  gonococcus 
the  cornea  was  injured.  In  gonorrheal  ophthalmia  the  conjunctiva  is 
slightly  reddened  at  first  and  a  profuse  secretion  of  thin,  glairy  mucus  is 
formed.  This  soon  changes  to  pus,  often  of  a  bright-yellow  color,  and  the 
tissues  become  a  deeper  and  brighter  red.  Should  the  infection  proceed 
unchecked  the  pupil  will  be  contracted,  the  cornea  will  gradually  become 
cloudy,  iritis  and  adhesions  will  develop,  ulcer  and  perforation  of  the 
cornea  may  result,  pus  may  form  in  the  anterior  chamber,  and  the  eye 
may  be  lost.  Catarrhal  conjunctivitis  may  fellow  the  subsidence  of 
acute  symptoms. 

Tetanus  Neonatorum. — Symptoms  caused  by  toxemia  of  the  tetanus 
bacillus  commonly  appear  during  the  first  and  second  weeks,  raiely  later 
than  the  third  week.  Trismus  is  the  pred  minating  symptom,  followed 
by  spasms  of  the  muscles  of  t  unkand  extremities,  dysphagia,  dyspnea, 
cyanosis,  cardiac  failure,  and  incontinence.    Death  is  the  usual  ending. 

Duration. — Ordinarily  the  infections  last  from  two  to  five  days,  though 
cases  of  less  than  twenty-four  hours'  duration  have  been  reported,  and 
others  may  linger  two  weeks  or  more. 

Prognosis  is  very  grave.  Cases  which  do  not  terminate  in  rapid  death 
may  go  on  to  athrepsia,  chronic  digestive  disturbances,  and  severe  anemia. 

1  Inaug.  Diss.,  Halle,  1903.  ^  Lancet,  1903,  vol.  ii.  p.  163. 


58  DISEASES  A.\D  I\  J  CRIES  OF   THE   XEWBORN 

Pathological  Histology. — There  is  always  parenchymatous  degenera- 
tion of  the  organs,  and  often  the  liver  shows  fatty  changes  as  well. 
Hemorrliagos  into  the  skin  and  mucous  membranes,  as  well  as  under- 
neath tlie  pleura,  jx'ricaridiuni,  and  (ilisson's  capsule,  are  very  common. 
Swellinti  of  the  spleen  and  lymph  nodes,  pneumonia  or  pulmonary  con- 
gest4on  are  the  rule.  Thrush  in  the  mouth  and  esophagus  and  ulcers 
at  any  point  in  the  intestinal  tract  are  among  the  less  frequent  lesions, 
while  pus  in  the  umbilical  vessels  and  in  the  liver,  as  well  as  on  any  of 
the  serous  menil^ranes,  may  be  found. 

Treatment.— The  treatment  of  the  various  infections  of  the  newborn 
varies  with  the  organ  infected.  At  the  umbilicus,  in  the  mouth  and  the 
nostrils  local  antisepsis  may  lie  attempted  with  a  fair  prospect  of  success. 
It  must  Ix^  remembered  that  infants  are  very  susceptible  to  mercurial 
and  carbolic  poisoning,  and  hence  very  dilute  solutions  or  mild  anti- 
septics only  should  be  employetl. 

Boric  acid  or  salt  .solution  may  be  used  freely  and  usually  without 
injury.  Care  must  be  taken  not  to  spread  infection  l)y  injuring  the 
tissues  through  harsh  manipulation,  (rentle  irrigation,  as  the  use  of 
a  spray,  is  especially  valuable. 

The  breasts  of  the  newborn  may  Ix^  dressed  with  sterile  gauze  com- 
presses soaked  in  boric  acid  solution.  They  must  not  be  handled  nor 
squeezed. 

In  pulmonary  infection  antisepsis  is  impossible  and  the  infant  must 
be  treated  by  supportive  measures  only.  Oxygen  may  be  inlialed  and 
it  is  necessary  to  give  artificially  digested  nourishing  food  at  intervals 
and  as  much  alcohol  as  the  infant  can  possibly  digest.  Restlessness  and 
fever  are  Ixvst  controlled  by  the  external  application  of  cold  by  either 
.sponging  or  the  use  of  compresses. 

In  infection  of  the  intestine  I  believe  in  the  importance  of  free  irriga- 
tion with  salt  .solution.  Tlie  free  use  of  water  as  a  drink  is  important 
in  all  intestinal  infections. 

In  diphtheria  the  value  of  .serum  by  injection  is  e.stabli.shed.  In 
tetiunis  the  value  of  serum  is  uncertain  as  it  is  used  after  toxemia  has 
developed.  Chloral  hydrate  in  do-ses  of  0.06  gm.  (gr.  j)  by  mouth,  or 
rectum,  repeated  every  few  hours  is  of  positive  benefit  and  may  be 
curative  in  late  cases.     Warm  baths  have  a  .sedative  effect. 

The  value  of  Crede's  prophylactic  treatment  in  ophthalmia  has  of 
recent  vears  been  much  discussed. 

Kraenzkamp,^  among  4.500  children  with  whom  Crede's  prophylactic 
treatment  was  carried  out,  saw  ophthalmia  in  but  11  cases,  of  which 
2  onlv  were  severe.  Some  prefer  the  use  of  argATol  in  10  per  cent, 
.solution  as  Ixing  absolutely  without  danger.  Rosner  obtained  the  l)est 
results  by  using  within  the  eye  10  per  cent,  .solution  of  protargol  and 
cleaning  the  lids  with  a  3  per  cent,  solution  of  boric  acid. 

BischofP  observed  symptoms  of  irritation  in  80  per  cent,  of  cases  in 

»  Inaug.  Diss.,  Halle,  1903.  *  Wiener  med.  Blatter,  1903,  Band  xxvi..  No.  16. 

»  Centralblatt  f.  Gynak.,  1904,  Band,  xxvii.  p.  293. 


INFECTIONS  OF    THE   NEWBORN  59 

which  silver  was  used.  This,  however,  subsided  in  four  days  without 
injury.  Protargol  seemed  as  irritating  as  silver  nitrate  in  his  experience. 
Acetate  of  silver  seemed  less  objectionable.  He  considered  the  silver 
irritation  of  no  practical  importance.  Veverka,  among  1100  children 
treated  with  protargol,  observed  but  4  cases  of  ophthalmia,  and  these 
were  secondary  infections.  The  possibility  of  infection  attacking  the 
tear-duct  of  the  newborn  has  been  reported  by  Heimann.^  Additional 
testimony  to  the  value  of  the  acetate  of  silver  is  given  by  Scipiades.^ 
He  treated  200  newborn  children  with  1  per  cent,  solution  of  acetate  of 
silver  without  the  development  of  ophthalmia.  In  11  cases  the  remedy 
caused  free  secretion. 

The  majority  opinion  is  distinctly  in  favor  of  the  use  of  some 
preparation  of  silver  in  the  eyes  of  newborn  children  in  maternities. 
Whether  this  be  Crede's  method  as  originally  proposed,  or  the  use  of 
argyrol  or  protargol  in  from  1  to  10  per  cent,  solution,  or  acetate  of 
silver,  or  saturated  solution  of  boric  acid,  or  equal  parts  of  salt  solution 
and  boiled  water,  must  be  left  to  the  judgment  of  the  responsible  physi- 
cian. Personally,  I  have  seen  good  results  in  hospital  practice  by  giving 
all  mothers  a  preliminary  vaginal  douche  of  lysol  and  green  soap,  and 
by  using  boric  acid  solution  in  the  eyes  of  the  infant.  In  private 
houses,  with  patients  of  known  character,  I  have  not  always  found  it 
necessary  to  employ  Crede's  prophylactic  treatment. 

When  ophthalmia  develops  the  most  prompt  and  vigorous  treatment 
is  necessary.  The  child  should  be  isolated  in  charge  of  special  nurses. 
In  the  acute  stage  cold  should  be  appHed  constantly  but  very  carefully 
with  small  compresses  taken  from  a  cake  of  ice. 

Silver  preparations  may  be  dropped  into  the  eye,  followed  by  salt 
solution.  If  argyrol  or  protargol  be  used,  salt  solution  is  considered 
unnecessary.  Irrigation  is  of  decided  value.  A  fountain  syringe  in 
whose  tube  is  placed  a  small  glass  pipette  like  a  medicine  dropper, 
delivers  a  small  stream  of  antiseptic  fluid  without  force.  The  infant  is 
placed  across  the  nurse's  lap  with  the  infected  eye  lower  than  the  other. 
The  non-infected  eye  should  be  protected  by  sterile  gauze  or  cotton  and 
bandage.  The  fluid  is  allowed  to  run  from  the  inner  canthus  down- 
ward and  outward,  thus  avoiding  infection  of  the  healthy  eye.  I  have 
found  alternate  irrigation  with  1 :  8000  bichloride  solution  and  saturated 
solution  of  boric  acid,  using  one  of  these  every  two  hours  and  each  of 
them  every  four  hours,  to  be  of  great  benefit.  The  eyes  should  be  very 
gently  dried  with  sterile  linen  or  gauze  after  irrigation.  Should  the 
pupil  be  contracted  it  should  be  dilated  with  atropine.  If  the  case 
improves,  treatment  should  be  made  less  frequent,  the  silver  may  be 
discontinued  and  bichloride  omitted,  and  irrigation  with  boric  acid 
solution  or  salt  solution  will  be  sufficient.  If  the  infant  seems  depressed 
by  the  use  of  cold  and  the  redness  subsides,  the  use  of  ice  may  be 
omitted.     It  should  in  any  case  be  discontinued  as  soon  as  possible. 

It  is  difficult  to  give  the  precise  statistics  of  the  results  of  ophthalmia. 

1  Deut.  med.  Woch.,  1903,  Band  xxix.  p.  86.  °-  Samml.  klin.  Vortr.,  Leipzig,  1902,  No.  345. 


60  DISEASES  AM)   IS.IVRIES  OF   THE   NEWBORN 

In  my  oxpcrlence  (•onsidcral)!^  and  jK'nnancnt  daniagr  to  the  eye  is 
rare.     Tlie  coniplrtc  loss  of  the  eye  is  seldom  observed. 

The  physic-ian  should  not  forget  to  warn  nurses  and  attendants  of 
the  danger  of  eontagion. 

Icterus. — Idiopathie  or  primary  ieterus  in  the  newborn  infant  is  dne 
to  some  disturbance  of  the  j)hysiol()gieal  rearrangement  of  fnnetions 
which  takes  place  immediately  after  birth.  Wiiether  the  fault  lies  in 
the  blood  or  in  the  liver  has  not  been  proved  as  yet.  Jaundice  is 
recorded  in  newly  bo;n  infants  in  35  to  75  per  cent,  of  the  cases. 

Secondary  ieterus  may  be  one  of  the  symptoms  of  a  general  sepsis, 
or  it  may  be  due  to  interstitial  hepatitis  (usually  of  syphilitic  origin),  to 
obliteration  of  the  bile-ducts,  or  to  blocking  of  the  common  duct  by 
catarrhal  inflammation  or  rarely  by  a  calculus. 

In  the  congenital  cases  Griffith'  inclines  to  the  view  that  there  is  a 
failure  of  d(>velo])ment.     The  course  of  the  disease  is  not  acute. 

Prognosis  and  Treatment. — The  primary  cases  recover  spontaneously. 
Of  the  secondary  cases,  those  due  to  sepsis  are  often  fatal,  those  due  to 
obliterated  bile-ducts  invariably  so. 

Where  there  is  a  catarrhal  obstruction  simple  saline  aperients  are 
sufficient  to  relieve  the  sym])t()ms.  Jaundice  associated  with  syphilis 
clears  up  with  mercurial  treatment.  In  cases  of  jaundice  due  to  con- 
genital occlusion  of  the  bile-ducts  treatment  is  entirely  symptomatic  and 
almost  entirely  without  result. 

Pemphigus. — Pemphigus  is  an  infection  of  the  skin  not  infrequent 
in  the  newborn.  It  may  be  distinguished  from  syj)hilitic  j)emphigus 
from  the  fact  that  it  does  not  attack  the  soles  of  the  feet  and  the  palms 
of  the  hands,  that  it  is  contagious,  and  that  it  yields  to  local  treatment. 
Staphylococcus  pyogenes  albus  and  ain*eus  are  the  organisms  almost 
invariably  found  in  the  fluid  of  the  bulUc  which  characterize  the  dis- 
ease. General  symptoms  may  or  may  not  accompany  or  precede  the 
eruption.  Mild  antisepsis  of  boric  acid,  sterile  dressings,  and  careful 
feeding  and  stimulation  are  effectual. 

Syphilis. — The  infant  may  be  apparently  healthy  at  birth,  and  char- 
acteristic symptoms  may  not  appear  until  several  weeks  later.  On  the 
other  hand,  severe  cases  may  show  an  eruption  at  birth,  consisting  of 
papules,  pustules,  or  bulhe,  especially  numerous  on  the  palms  and  soles. 
The  contents  of  the  bullje  are  often  blood-stained.  Emaciation  and  a 
general  appearance  of  old  age  accompany  the  eruption.  Soft  cords  with 
or  without  hemorrhage  are  conmion  in  these  cases. 

In  infants  who  present  no  symptoms  at  birth  the  characteristic 
snuffles,  fissures  of  the  lips  and  anus,  excoriation  of  the  buttocks,  an<l 
eruption  first  apparent  on  the  face  and  hands  may  not  develop  for  two 
to  six  weeks,  but  they  are  usually  present  within  two  months  after  birth. 
Hemorrhages  from  the  mucous  membranes  are  very  connnon. 

Treatment. — This  is  the  usual  treatment  detailed  under  the  special 
heading  on  Syphilis. 

'  Archives  of  Pediatrics,  April,  1905,  p.  257. 


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SECTION  II. 
DEVELOPMENT,  GKOWTH  AND  HYGIENE. 

By  LEROY  MILTON  YALE,  M.D. 


CHAPTER  IV. 

CHANGES  AFTER  BIRTH— HYGIENE  OF  THE  INFANT  AND 

NURSERY. 

To  further  our  knowledge  of  the  conditions  intimately  associated 
with  growth  and  development,  it  is  essential  that  we  should  revert 
briefly  to  some  of  the  organs  of  the  infant  that  were  studied  in  the 
previous  chapters  and  which  we  must  now  regard  from  their  physio- 
logical standpoint. 

At  the  beginning  of  extrauterine  life  changes  take  place  in  the  circula- 
tion which  are  best  understood  by  an  inspection  of  the  plate  (Plate  III.) 
of  the  circulation  of  the  blood  through  the  vessels  of  the  placental 
attachment  before  the  infant  begins  its  separate  existence. 

Circulation. — ^The  circulation  of  the  fetus  up  to  the  institution  of 
respiration  and  the  cessation  of  flow  through  the  umbilical  cord  is  in 
brief  as  follows:  Red  blood  enters  the  fetus  through  the  umbilical  vein. 
Beneath  the  liver  the  vein  divides;  one  portion,  carrying  the  larger  part 
of  the  blood,  enters  the  transverse  fissure.  This  blood,  already  somewhat 
mixed  with  darker  blood,  reaches  the  vena  cava  by  way  of  the  hepatic 
veins.  The  smaller  current  goes  directly  to  the  vena  cava  through  a 
continuation  of  the  umbilical  vein,  called  the  ductus  venosus.  This 
blood,  still  largely  red,  meets  in  the  cava  blood  returning  from  the 
abdominal  veins.  This  mixed  blood  is  still,  however,  as  nearly  arterial 
in  character  as  any  sent  to  any  organ,  except  the  liver,  during  fetal  life. 
In  the  right  auricle  it  meets  the  blood  coming  from  the  superior  vena 
cava.  In  earlier  fetal  life  it  is  thought,  from  the  anatomical  structure 
of  the  heart  at  that  time,  that  the  two  currents  do  not  mix  very  much, 
that  from  below  being  directed  by  the  Eustachian  valve  through  to 
the  foramen  ovale  to  the  left  auricle.  The  flow  coming  back  from  the 
undeveloped  lungs  very  slightly  alters  the  character  of  the  blood  current. 
It  is  then  thrown  by  the  left  ventricle  through  the  aortic  arch,  the 
carotids,  and  subclavians  to  the  head  and  upper  extremities.     These 

(61) 


62  1)E\  i:iA>I'MEST,   (iROWTlI   ASD   IlYdlESE 

parts  an\  and  jjroUahly  coiisrciiuiitly,  far  more  (IcvclojH'd  tlian  the  rest 
of  the  l)()(lv,  more  cspt'cially  in  the  early  and  middle  jK-riod  of  fetal  life. 
The  eurrent  from  the  superior  vena  eava,  however,  prohahly  deseends 
directly  to  the  right  ventricle,  and  is  thrown  into  the  pulmonary  artery. 
The  hranehes  of  this  artery  cannot  distribute  much  blood  to  the  still 
une\])andcd  luii<;s,  and  the  bulk  of  the  flow  is  diverted  to  the  ductus 
arteriosus  (which  is,  in  efiVct,  a  branch  of  the  pulmonary  artery),  and 
delivered  into  the  descending  aorta  just  below  the  aich.  As  the  fetus 
nears  term,  however,  the  anatomical  changes  hinder  the  free  flow  through 
the  foramen  ovale,  and  the  course  of  the  blood  approaches  more  nearly 
the  postnatal.  The  lower  extremities,  therefore,  for  the  most  part, 
i*eceive  blood  which  has  alr(>ady  done  duty  in  the  uj)j)er  extrcTuities  and 
in  the  head.  This  is  probably  the  main  reason  of  tlieir  relatively  small 
size.  The  return  circulation  to  the  placenta  is  by  way  of  the  internal 
iliac,  hypogastric,  and  umbilical  arteries.  The  distinction  between 
arterial  and  venous  blood,  so  readily  recognized  after  birth,  does  not 
e.xist  in  fetal  life  after  the  j)lacental  l)lood  has  entered  the  liver,  but  the 
two  sorts  are  mi.xed  in  various  degrees  in  dilferent  parts  of  the  body. 
(See  Plate  III.) 

Changes  at  Birth. — ^As  soon  as  tlie  respiration  is  thoroughly  established 
the  circulation  of  blood  is  greatly  increased  in  the  lungs.  \Vith  the 
functionating  of  these  organs,  the  blood  returning  from  them  is  no 
longer  dark.  As  soon,  too,  as  the  respiration  is  (\stablislied  the  flow 
through  the  umbilical  vessels  is  usually  arrested  by  ligation,  and  umbil- 
ical veins  and  the  ductus  venosus  fill  with  clots,  and  usually  within  a 
few  (lavs  are  practically  obliterated  and  l)ec()me  fibrous  cords.  That 
part  of  the  umbilical  artery  which  within  the  abdomen  of  the  infant  is 
called  the  hypogastric  artery  is  also  obliterated,  save  a  small  branch 
to  the  blad(ler. 

The  changes  in  connection  with  the  circulation  within  the  heart  itself 
are  more  important  clinically,  because  of  cardiac  symj)toms  associated 
with  the  persistence  of  fetal  conditions.  The  ductus  arteriosus  dis- 
appears by  the  same  obliterative  process  as  the  umbilical  vessels  and 
ductus  venosus,  and  is  closed  usually  within  ten  days  after  birth.  The 
foramen  ovale,  which,  as  already  mentioned,  does  not  carry  a  large 
amount  of  blood  in  the  latter  part  of  fetal  life,  becomes  still  more 
obstructed  after  birth  by  the  growth  of  a  valve-like  flap.  Although  the 
closure  remains  not  absolutely  comj)lete  in  very  many  cases  for  months 
after  birth,  it  is  nevertheless  functionally  aderjuate  very  .shortly  after 
birth.  Persistent  patency  of  the  foramen  to  a  degree  to  cause  symptoms 
is,  nevertheless,  not  a  very  rare  condition. 

The  activity  of  the  circulation  diminisluvs  with  the  growth  of  the  body, 
and  probably  necessarily;  for  while  the  weight  of  the  heart  bears  about 
the  same  proportion  to  the  body  weight  in  the  early  years  as  in  adult 
life,  the  capacity  of  the  vascular  system  and  the  length  of  the  vessels  to 
be  served  diminishes  the  rapidity  of  the  circulation.  Similarly,  with 
the  increase  in  body  length,  the  pulse  rate  falls.  This  rate  is  very 
variable  in  individuals;   females  have  a  higher  rate  than  males,  and 


CHANGES  AFTER   BIRTH  63 

in  the  same  individual  it  may  vary  rapidly  from  time  to  time,  espe- 
cially in  very  young  children.  Observers  give  very  different  estimates 
for  different  ages.  Holt's  table  gives  the  lowest  figures,  but  he  states 
that  they  were  taken  when  the  infant  was  asleep  or  perfectly  quiet, 
which  the  others  do  not.    Holt  gives: 

Six  to  twelve  months 105  to  115  per  minute. 

Two  to  six  years 90tol05    "        " 

Seven  to  ten  years 80  to   90    "        " 

Eleven  to  fourteen  years 75  to   85    "        " 

It  is  quite  certain  that  the  pulse  rate  is  less  if  counted  by  a  nurse  to 
whom  the  child  is  accustomed  than  if  taken  by  the  physician,  who  is 
not  so  familiar  a  person.  The  physician  who  is  a  stranger  must  expect 
higher  rates  than  when  he  is  acquainted  with  the  child. 

The  Stomach. — The  capacity  of  the  stomach  is  quite  variously 
estimated  by  different  writers,  and  probably  because  of  the  different 
methods  employed.  It  is  not  perfectly  easy  to  determine  when  the 
stomach  is  normally  distended  and  not  overdistended.  Holt's  summary 
of  his  inquiries  is:  "In  brief,  the  average  capacity  was,  at  birth,  one 
and  one-fifth  ounces;  at  three  months,  four  and  a  half  ounces;  at  six- 
months,  six  ounces;  at  twelve  months,  nine  ounces."  Rotch's  estimates 
are,  however,  considerably  smaller.  Whatever  estimates  are  accepted, 
they  will  give  no  justification  for  the  enormous  quantity  of  liquid  food 
often  fed  to  infants  at  one  meal.  The  stomach  is  more  directly  a  part 
of  the  intestinal  tube  than  in  the  adult. 

The  Intestines. — Probably  the  most  important  fact  regarding  the 
intestines  to  the  practitioner  is  the  great  relative  length  and  very  pro- 
nounced S-shaped  curve  of  the  sigmoid  flexure.  This  peculiarity  has 
to  be  borne  in  mind  when  the  colon  has  to  be  irrigated,  and  instances 
have  been  reported  in  which  the  tardy  emptying  of  this  prolonged 
flexure  has  led  to  needless  interference  for  supposed  imperforation. 
The  intestines  are  liable  to  distention  to  gas  in  babies  who  are  artificially 
fed,  and  the  pressure  of  the  gas  may  still  further  change  their  position. 

The  Liver. — ^The  liver  is  notably  large  in  infancy,  being  at  birth 
proportionally  about  two-thirds  larger  and  for  the  first  three  years  of 
life  still  at  least  one-third  larger  than  in  the  adult. 

The  Bladder. — It  is  necessary  to  note  that  the  bladder  in  infancy  may 
occupy  a  much  higher  position  than  in  adult  life.  Being  quite  dis- 
tensible after  the  earliest  weeks,  and  having  quite  lax  pelvic  attachments, 
it  easily  rises  above  the  pubis  and  may  be  a  source  of  confusion  to  the 
diagnostician,  as  well  as  to  the  operator. 

The  Special  Senses. — It  is  doubtful  whether  any  exist  at  birth.  The 
only  one  which  I  have  been  able  to  see  e\idence  of  is  smell,  and  this 
chiefly  from  the  beha\aor  of  the  infant  when,  if  really  awake,  it  is  placed 
upon  the  breast.  The  infant's  eyes  certainly  are  affected  by  strong 
light  at  birth,  as  evidenced  by  the  closing  of  the  lids  against  it.  Later, 
it  seems  to  be  interested  in  gazing  at  illuminated  objects.  But  sight 
in  the  ordinary  sense  of  distinct  vision  cannot  occur,  except  occasionally 


64  DEVELOPMENT,   GROWTH  AXD   HYGIENE 

by  accidental  adjustment,  until  the  co-ordination  of  the  ocular  muscles 
is  estahlishcd,  which  may  require  several  months,  possibly  five  or  six. 
Hearing  is  developed  fairly  early,  usually  within  six  or  eight  weeks. 
In  my  opinion  much  that  has  been  written  about  early  hearing  is  due 
to  its  confusion  with  the  recognition  of  concussion,  the  infant  being 
startled  by  the  jar,  not  by  the  sound,  and  being  disturbed  nearly,  if  not 
quite,  as  easily  by  the  former  when  noiseless.  It  is,  of  course,  not 
intended  to  deny  the  great  sensibility  of  young  children  and  even  infants 
to  sound,  both  as  to  degree  and  quality,  after  the  hearing  is  well  estab- 
lished. It  is  claimed  by  some  that  taste  is  developed  very  early,  if 
indeed  it  be  not  present  at  birth.  I  have  been  unable  to  verify  the 
latter  claim.  But  there  is  no  doubt  that  quite  early  differences  of 
taste  are  recognized.  It  is  not  easy  to  decide  how  early,  because  some 
things  not  agreeable  to  adults  or  older  children  do  not  give  offence  to 
little  children.  Pungent  substances  arc  usually  objectionable  to  children, 
and  I  have  had  doubts  to  what  degree  the  irritation  caused  by  such 
articles  gave  rise  to  an  appearance  to  a  disliko  for  the  taste  of  them. 
General  bodily  or  tactile  sensihilitij  is  not  very  acute  in  the  newborn; 
nor  is  sensibility  to  pain;  but  both  sorts  of  sensibility  are  rapidly 
developed. 

The  Muscular  System. — The  development  of  the  muscular  system  is 
more  striking  as  regards  gain  in  co-ordination  than  in  actual  gain  in 
power;  for  example,  the  chance  blow  delivered  by  tlie  infant's  hand  or 
foot  demonstrates  considerable  muscular  power  long  before  the  child 
can  co-ordinate  its  motions.  Automatic  closing  of  the  hand  upon  an 
object  occurs  very  early,  but  not  until  after  three  months  an  ill  it  be 
likely  to  purposely  grasp  anything.  It  will  be  at  least  another  three 
months  before  it  can  sit  upright.  Soon  after  this  feat  is  accomplished 
it  may  learn  to  creep  or  to  hitch  itself  along  in  a  sitting  posture  upon 
the  floor.  With  the  last  quarter  of  its  first  year  usually  come  attempts 
at  climbing  up  beside  chairs  or  the  parent's  knee,  the  time  of  standing 
gradually  increasing  until  it  can  stand  alone.  Great  variation  within 
strict  limits  of  health  exists  as  to  all  these  developments,  and  particu- 
larly as  to  walking  without  aid  and  habitually.  This  usually  occurs 
within  the  first  quarter  of  the  second  year.  Debility  from  any  cause 
may  retard  it.  Overfatness  from  peculiarities  of  feeding  may  increase 
the  difficulty  of  balancing,  and  so  hinder  the  free  walk  of  a  child  who 
has  been  for  some  time  able  to  stand  with  support.  No  urging  of  the 
baby  should  be  permitted.  Granted  ordinary  mental  development,  it 
will  walk  as  soon  as  it  properly  can,  but  it  must  have  wide-toed  slippers 
or  shoes  that  will  not  cramp  the  feet  and  add  to  the  difficulty  in  balancing. 
Defective  children  are,  of  course,  not  here  considered. 

Speech. — Speech  is  developed  very  differently  in  different  children. 
Not  only  does  the  first  attempt  to  speak  vary  considerably  in  time,  but 
the  method  of  development  differs.  Given  apparently  equal  mental 
development  and  equal  ability  to  understand  speech,  one  child  will 
articulate  with  great  clearness,  while  another  will  pour  out  a  great  flow 
of  conversation,  the  meaning  of  which  only  the  initiated  or  the  very 


GROWTH   OF  SPECIAL   PARTS  65 

imaginative  admirers  can  guess.  Occasionally,  a  child  is  met  with  who 
is  evidently  intelligent,  who  seems  to  shrink  from  speech  until  it  can 
speak  well.  But,  as  a  rule,  inteUigent  children  make  some  attempt 
by  the  completion  of  a  year  and  "put  words  together"  during  the 
second.  Occasionally,  one  speaks  with  precision  at  two  years  of  age, 
and  I  recall  one  of  this  age  who  rolled  out  with  phonographic  accuracy 
the  sonorous  Greek  hues  of  the  "Iliad."  Owing  to  the  almost  automatic 
position  of  the  tongue-tip  in  making  their  sounds,  p,  m,  t,  and  d  are 
usually  the  first  articulated  consonants,  and  as  a  consequence  "papa," 
"mamma,"  "dad"  are  among  the  first  words  and  have  become  accepted 
as  endearing  names  in  most  tongues. 


GROWTH  OF  SPECIAL  PARTS. 

In  addition  to  the  foregoing  a  few  words  may  be  said  in  regard  to 
the  proportions  and  peculiarities  of  some  parts  and  regions  of  the  body, 
both  because  upon  these  local  changes  the  general  changes  depend  and 
because  the  local  changes  are  intimately  connected  with  important 
physiological  facts. 

The  Head. — The  head  participates  in  the  general  rapidity  of  growth 
of  the  first  year,  so  that  at  the  end  of  twelve  months  its  circumference 
is  almost  a  third  larger  than  at  birth,  and  quite  a  third  larger  at  a  year 
and  a  half.  The  increase  in  circumference  is  thereafter  slower,  say 
5  cm.  (two  inches)  from  eighteen  months  to  five  years,  and  2.5  cm.  (one 
inch)  or  thereabouts  during  the  succeeding  ten  years.  But  the  size  of 
the  head  at  puberty  and  thereafter  varies  very  much  in  proportion  to 
the  body  height.  At  puberty  the  average  circumference  is  rather  more 
than  one-third  of  the  total  height,  at  the  completion  of  growth  rather 
less  than  one-third. 

With  this  growth  marked  changes  in  proportion  occur.  At  birth  the 
face  is  noticeably  small  as  compared  with  the  cranial  vault,  so  that  the 
centre  of  the  vertical  diameter  is  at  the  top  of  the  orbit  instead  of  at  the 
pupil,  as  in  the  adult.  The  mandible  does  not  descend  into  the  prom- 
inent chin  of  maturity,  and  is  but  little  below  the  occipital  condyles.  So 
that  infancy  bears  a  remarkable  resemblance  to  toothless  age.  The 
ridges  of  the  skull  are  little  marked,  the  frontal  and  parietal  prominences 
decidedly  so.  The  bones  of  the  vault  have  no  diploe.  Of  more  clinical 
importance  is  tlie  fact  that  the  sutures  exist  only  potentially  in  the 
approximating  margins  of  the  component  bones.  The  frontal  or 
metopic  suture  still  exists.  The  parietal  bones  are  incomplete,  their 
missing  anterior  corners  and  the  divided  frontal  leaving  the  space 
known  as  the  anterior  fontanel,  usually  about  3.81  cm.  (one  and  one-half 
inches)  anteroposteriorly  and  one  inch  transversely.  A  similar  defect 
at  the  approximation  of  the  posterior  angles  of  the  parietals  to  the 
occipital  makes  the  posterior  (triangular)  fontanel  not  above  one-half 
the  size  of  the  anterior.  The  other  fontanels  are  scarcely  of  clinical 
importance.  Nor  is  the  composite  nature,  at  this  age,  of  the  occipital 
5 


66  DEVELOPMESr,   CROWTII   AM)   IIYHIENE 

and  temporal  bones.  But  the  al)senee  of  the  mastoid  process  is  wortli 
reineiHl)eriiii^  as  bearing  upon  aural  diseases,  "^rhe  osteal  development 
of  the  cranial  base  and  the  gradual  fusion  of  the  centres  of  ossification 
are  very  interesting,  but  of  moderate  clinical  importance.  It  may  be 
worth  while  to  remember  that  the  fusion  of  the  basal  parts  of  the  occipital 
and  sphenoid  is  one  of  the  last  to  take  })lace,  only  in  fact  when  the 
organism  is  practically  mature.  The  closing  of  the  anterior  fontanel, 
which  occurs  on  the  average  at  about  the  age  of  eighteen  or  twenty 
months,  is  clinically  the  most  important  of  all  these  cranial  bony  changes. 
The  changes  and  distortions  of  the  skull  as  the  result  of  disease  or 
dyscrasia  do  not  belong  to  this  section. 

The  amount  of  hair  upon  the  seal})  at  birth  may  vary  from  complete 
baldness  to  exuberance,  but  it  is  usually  scanty.  This  hair  is  generally 
lost  within  a  few  weeks  and  is  replaced  by  another  growth,  ordinarily 
of  a  different  color  from  the  first. 

The  Chest.— The  chest  in  the  newborn  is  noticeably  small.  So  long 
as  the  placenta  performs  the  respiratory  function  of  the  lungs,  the  latter 
remain  only  as  reserve  or  accessory  organs,  the  hmg  tissues  grow  ing  to 
meet  their  prospective  use,  but  the  air  vesicles  not  expanding.  Hence,  the 
small  size  of  the  chest,  which  is  usually  at  birth  rather  less  in  circum- 
ference than  the  head  and  still  less  when  compared  with  the  abdomen. 
By  the  age  of  two  years  the  circumference  of  the  chest  usually  is  as  great 
as  that  of  the  head,  and  thereafter  gradually  and  increasingly  gains 
proportionally.  If  it  be  remembered  that  the  average  gain  in  head 
circumference  is  not  much  more  than  an  inch  between  five  and  fifteen 
years,  while  that  in  chest  circumference  is  about  ten  inches,  this  relative 
change  of  projjortion  will  be  emphasized. 

The  Abdomen. — The  abdomen  at  birth  is  ordinarily  larger  than  the 
chest  and  even  a  little  larger  than  the  head,  but  the  rapid  growth  of 
head  and  chest  very  soon  destroys  this  predominance  and  the  whole  trunk 
varies  little  in  its  circumferences  during  infancy,  so  that  "baby  has  no 
waist"  is  a  nursery  axiom.  In  the  periods  of  second  infancy  and  adoles- 
cence the  circumference  of  the  chest  gains  upon  that  of  the  abdomen,  the 
relative  size  of  the  latter  varying  much  according  to  diet  and  tendency 
to  fat. 

The  Spinal  Column. — The  fart  regarding  the  spinal  column  of  an 
infant  which  first  attracts  attention  is  its  great  flexibility,  especially 
in  the  anteroposterior  direction.  This  persists  to  a  very  great  degree, 
however,  through  childhood  and  even  to  adult  life.  So  prominent  is 
this  that  any  spinal  rigidity  in  a  child  should  at  once  be  investigated 
as  evidence  of  disease,  probably  of  the  column  itself.  In  the  newborn 
this  flexibility  of  the  spine  is  so  great  that  the  distinctive  curves  do  not 
exist,  save  that  the  occiput  and  sacrum  present  permanent  posterior 
convexity.  Between  these  the  spinal  column  usually  falls  into  a  single 
long  curve,  the  direction  of  its  convexity  being  determined  by  the 
position  in  which  the  child  is  placed  or  held.  As  the  lower  extremities 
become  more  and  more  placed  in  the  position  of  exiension,  the  traction 
of  the  iliopsoas  muscles  helps  to  give  a  lumbar  curve  with  forward  con- 


GROWTH   OF   SPECIAL   PARTS  67 

vexity.  As  the  child  learns  to  stand  and  walk  this  curve  calls  for  a 
compensating  dorsal  curve  in  balancing,  the  development  of  the  chest 
assisting  in  its  formation.  The  total  curve  begins  thereafter  to  resemble 
that  seen  in  the  developing  child,  save  that  the  cervical  curve  is  less 
evident.  The  infant  is  often  said  to  have  no  neck.  In  fact,  the  pro- 
portion of  the  cervical  vertebrae  to  the  whole  column  is  not  so  very  much 
different  from  what  it  is  later,  but  the  region  is  enveloped  in  fat  or  in 
loose  integument  and  hidden  behind  and  masked  by  the  relatively 
enormous  head,  so  that  the  occiput  seems  to  rest  upon  the  shoulders. 

The  Teeth. — At  birth  the  teeth,  both  of  the  temporary  and  permanent 
sets,  exist  rudimentahy  in  the  jaw.  As  has  already  been  noted,  the 
mandible  has  little  angle  at  birth,  yet  its  gum  does  not  quite  touch  that 
of  the  upper  jaw.  The  temporary  or  so-called  milk  teeth  begin  their 
development  early  in  fetal  life,  the  process  advancing  slowly  and  con- 
tinuing long  after  their  eruption  through  the  gums.  Very  rarely,  indeed, 
teeth  are  found  to  have  pierced  the  gum  at  birth.  In  a  case  in  my  own 
practice  such  a  tooth  proved  to  be  a  supernumerary  one.  The  infant's 
mother  and  maternal  grandmother  each  had  a  supernumerary  infantile 
incisor  persisting  among  the  permanent  teeth.  The  infant's  tooth, 
however,  proved  to  be  deciduous  and  was  replaced,  contrary  to  the  rule, 
by  a  supernumerary  incisor  in  the  permanent  set. 

"Wliile  the  average  time  of  the  eruption  of  the  teeth  is  pretty  well 
agreed  upon,  individual  variations  are  very  wide  within  the  limits  of 
apparent  good  health.  In  artificially  fed  children  in  dispensary  practice 
the  average  date,  tooth  for  tooth,  is  later  than  in  breast-fed  infants. 
Whether  this  difference  exists  under  well-managed  artificial  feeding 
I  have  not  enough  statistics  to  state,  but  I  am  inclined  to  think  that  a 
slight  difference  still  exists  as  compared  with  the  best  breast  nutrition. 
I  also  place  a  good  deal  of  stress  upon  family  peculiarities — paternal 
quite  as  often  as  maternal.  In  some  famihes  even  v/ith  good  breast 
feeding  and  evident  good  nutrition  the  teething  will  be  late.  On  the 
other  hand,  I  recall  in  a  forward  teething  family  a  child  cutting  teeth  in 
advance  of  the  average,  in  spite  of  very  poor  nutrition  and  pronounced 
infantile  scurvy.  This  child's  father  I  had  also  had  under  observation 
as  an  infant.  He  cut  his  first  tooth  at  four  months  and  had  sixteen 
teeth  at  sixteen  months.  It  should  always  be  kept  in  mind  in  tracing 
hereditary  peculiarities  that  the  child  is  not  to  be  compared  with  its 
parents,  but  its  parents'  childhood. 

The  temporary  set  contain  twenty  teeth — ten  upper,  ten  lower — 
namely,  in  either  jaw  four  incisors,  two  canines,  four  molars.  While 
the  order  of  their  eruption  varies,  so  that  this  is  differently  stated  by 
different  writers,  the  majority  agree  that  the  time  and  order  of  eruption 
are  nearly  as  follows: 

Eruption  of  Temporary  Teeth. 

Lower  central  incisors 6  to   9  months. 

Four  upper  incisors 8  to  12       " 

Lower  lateral  incisors  and  four  first  molars 12  to  15       " 

Four  canines 18  months  to  2  years. 

Four  second  molars 2  to  2}^  years. 


68 


f)h\'/:L<H'.\fh.\T,    (Ih'OW'Tll    A.MJ    IIYCIESE 


It  is  not  raiv  for  dentition  to  Wcgin  considcnihly  earlier  than  tlic 
earliest  date  just  given;  but  for  some  reason,  probably  the  disturbanee 
of  weaning,  the  date  of  the  eoming  of  the  teeth  in  the  third  and  subse- 
(|nent  groups  are,  in  my  ex])erienee,  less  likely  to  be  antieipated.  In 
eaeh  group,  except  the  incisors,  the  lower  teeth  usually  precede  the 
uppi*r  ( Fig.  19). 

All  the  teeth  of  the  temporary  set  have  succe.ssors  in  the  permanent 
.set,  the  germ  of  the  latter  being  attached  behind  the  sac  of  the  former. 
To  these  are  added  three  pairs  in  either  jaw .    The  first  of  the  permanent 


Fig.  19 

PERMANENT 

II         II 


TI 

H 

SECOND 

BI- 
CUSPID 

I 

FIRST 
MOLAR 

VII 

SECOND 
MOLAR 

vni 

THIRD 
MOLAR 

FIRST 
MOLAR 


SECOND 
MOLAR 


THIRD 
MOLAR 


VII 


VIII 


Diagram  showing  what  permanent  tooth  replaces  each  temporary  tooth,  aud  also  the  order  of 
succession  of  the  teeth  of  each  set.    (Gerrish.) 

set  to  appear  are  the  first  molars,  popularly  called,  from  the  usual  period 
of  their  eruption,  "the  six-year-old  molars."  Thereafter  the  order  of 
the  eru])tion  of  the  permanent  teeth  is  nearly  a  rey)etition  of  that  of  the 
temporary  set.     On  the  average  they  appear  about  as  follows: 

Ekcptiox  of  Pekmanent  Teeth. 

First  molars 6  years. 

Central  incisors 7  " 

Lateral  incisors S  "' 

First  bicuspids 9  " 

Second  bicuspids Id  " 

Canines 11  " 

Second  molars 12  " 

Wisdom  teeth  (third  molars) 17  to  25  " 


GROWTH   OF   SPECIAL    PARTS 


69 


These  ages  are,  of  course,  subject  to  some  variation. 

The  process  of  dentition,  especially  the  first,  is  often  attended  by 
local  discomfort  and  even  general  disturbance  of  the  digestive  and 
nervous  systems.  These  should  not,  however,  be  considered  as  a  normal 
condition  nor  neglected  as  "natural." 

The  Saliva. — The  saliva  plays  no  active  role  in  digestion,  nor  is  its 
cjuantity  considerable  until  the  third  or  fourth  month.  Investigators 
do  not  agree  as  to  its  actual  amount  at  early  periods.  The  amount, 
however,  is  manifestly  increased  at  the  time  mentioned,  and  very  much 

Fig.  20 


CENTRAL 
INCISOP 

Jaws  of  a  child  of  seven  and  a  half  years,  the  external  table  of  bone  having  been  cut  away  to 
show  the  stage  of  second  dentition.     (Testut.) 


so  as  the  beginning  of  dentition  approaches.  It  is  probable  that  these 
two  developmental  facts  are  ordinarily  merely  coincidental,  as  we  see 
pronounced  salivation  at  the  usual  time  even  if  dentition  is  greatly 
delayed.  Xevertheless,  the  flow  of  the  saliva  is  popularly  accepted  as 
the  herald  of  the  coming  of  the  teeth  and  usually  it  does  precede  dentition 
but  a  short  time.  When  the  flow  of  saliva  is  well  established  it  continues 
abundantly,  some  observers  even  considering  the  amount  at  one  year 
to  be  equal  to  that  of  the  adult. 


CHAPTER  V. 

GROWTH  AND  HYGIENE. 

Hygiene  has  hccn  dofined  to  be  "the  science  and  art  of  tlie  preser- 
vation of  heaUh."  Perhaps  this  is  as  good  as  any  short  definition,  but 
it  involves  th(>  presumption  that  the  word  liealtli  has  a  definite  nieaning 
to  the  reader.  For  the  purposes  of  this  chapter,  hygiene  may  be  taken 
to  mean  such  rules  as  to  surroundings,  conditions,  and  regimen  as 
conduce  to  the  normal  growth  and  development  of  a  child  and  the 
proper  functionating  of  all  its  organs.  Such  a  meaning  necessitates  a 
(lescrij)ti<)n  of  what  constitutes  the  normal  state — health,  in  other  words 
— in  infancy  and  cliildhood.  It  should  be  said  at  once  tliat  this  is  not  a 
fixed  one  in  any  particular,  save  as  we  may  accustom  ourselves  to  the 
idea  of  means  and  averages.  No  one  questions  that  breeds  of  animals 
widely  differing  from  each  other  may  be  equally  normal.  Racial  dis- 
tinctions in  man  are  usually  similarly  recognized.  In  the  same  environ- 
ment the  tall  and  the  short,  the  thin  and  the  stout  are,  within  limit,  all 
accepted  as  normal. 

To  distinguish  between  growth  and  development  is  not  always 
practicable  unless  the  meaning  of  the  former  be  restricted  to  mere 
increase  in  height,  bulk,  and  weight,  and  even  these  are  in  part  the  result 
of  the  develoj)mental  evolution  of  organs.  If  this  restricted  meaning  be 
adopted,  it  is  safe  to  say  that  growth  is  generally  less  important  than 
development,  and  that  perfection  of  function  is  most  important  of  all. 
I'iXcej)t  for  the  sake  of  clearness  this  matter  need  not  be  mentioned,  since 
here,  as  elsewhere,  increase  of  size  without  development  is  merely 
expansion,  not  growth. 

The  study  of  the  growth  and  external  development  of  children  from 
a  physiological  point  of  view  belongs  to  recent  years.  It  is  scarcely 
seventy  years  since  (^uetelet  published  the  measurements  which  are 
generally  assumed  as  our  starting  point,  while  the  ])ast  thirty  years — 
the  j)ast  twenty  in  fact — have  furnished  the  greater  part  of  what  is  now 
a  pretty  extensive  bibliography.  Physiologists,  anthropologists,  and 
especially  those  interested  in  the  application  of  the  physical  sciences 
to  the  ])roblems  of  jx'dagogy,  have  all  contrii)ute(l  to  the  growing  accu- 
mulations of  observations.  But  the  study  of  the  human  form  by  painters 
and  sculptors  is  very  old.  In  fact,  the  old  Greek  canons  have  never 
been  superseded.  Until  these  recent  years  works  by  artists  or  upon 
artistic  anatomy  were  our  best,  in  fact  our  only,  guide  as  to  the  pro- 
portions of  the  human  form.  The  artist  seeks  to  establish  an  ideal  or 
at  least  to  j)oint  out  the  nearest  concrete  approach  to  it;  while  the 
physiologist  and  the  pediatrist  seek  to  determine  the  ways  and  degrees 
(70) 


GROWTH   AXD   HYGIEXE 


71 


in  which  this  ideal  may  be  departed  from  within  the  range  of  normal 
variations.  These  artistic  studies  of  proportion  are  of  interest  to  the 
pediatrist,  to  the  general  practitioner,  and  to  anyone  who  has  the  care 
of  the  physical  development  of  children.  They  offer  him  an  ideal 
toward  which  to  train  those  he  cares  for,  while  the  averages  and  tables 
of  scientific  observers  give  him  the  laiowledge  of  what  are  existing  facts 
and  a  test  of  his  progress  toward  his  standard  of  perfect  success.  At 
the  present  moment  the  amount  of  data  gathered  by  scientific  men  is 
very  considerable,  but  more  are  still  needed,  and,  as  in  most  physical 
science,  the  broad  understanding  of  these  data  awaits  an  interpreter. 

The  growth  of  a  child  is  marked  not  merely  by  increase  in  stature, 
but  by  constant  change  in  the  proportion  of  the  parts  of  the  body. 
Discussion  of  these  changes  as  regards  the  external  figure  alone  has 


Fig.  21 


Birth, 
4  heads  high. 


2  years, 
5  heads  high. 


b  years, 
G  heads  high. 


filled  volumes,  while  here  but  a  few  paragraphs  can  be  devoted  to  them. 
It  will  save  repetition  and  probably  space  if  the  points  be  first  mentioned 
in  which  the  newborn  most  noticeably  differs  from  the  adult,  and  then 
the  steps  by  which  they  are  changed  in  the  course  of  growth.  Diagrams 
and  illustrations  will  still  further  save  words. 

The  first  diagram  (Fig.  21,  from  Stratz)  shows  the  comparative  size 
of  a  newborn  infant  50  cm.  (19.7  in.)  long  and  an  adult  of  ISO  cm. 
(5  ft.  11  in.,  nearly).  It  is  to  be  noted  that  this  height  is  ideal,  not  the 
average.  The  average  of  upward  of  190,000  American-born  men  in  the 
army  during  the  civil  war  was  very  nearly  .5  feet  8  inches.  The  length 
of  the  newborn  infant  is  differently  given  by  different  observers.  Holt 
found  it  in  some  lying-in  hospitals  of  New  York  52.07  cm.  (202^  inches), 
about  2\  cm.  more  than  above  sriven. 


72 


DFAKI.OPMEST,    (lUOWTH   A\'D   IIYCIEXE 


Ditforcnccs  of  |)n)j)orti(m  as  well  as  of  size  can  be  noted,  hut  the 
former  are  iniieh  more  clearly  shown  in  Fig.  22  (also  from  Stratz, 
Dcr  Kocrpcr  dcs  Kinclcs).  It  will  he  noticed  that  Fig.  21  gives  the 
adult  as  eight  heads  high.  This  is  in  accordance  with  the  ancient 
Greek  canon  an<l  is  still  accepted  as  an  artistic  rule  for  the  male  figure. 
The  medical  niau  nnist,  however,  not  expect  to  find  it  holding  good 
except  among  those  whose  occuj)ati()ns  or  amusements  give  the  body 
every  advantage.     In  other  words,  it  is  the  canon  of  the  athlete  rather 


Fig.  22 


Normal  stages  of  childhood;  outlines  from  Geyer.    The  second  period  nearly  corresponds  with 
that  of  the  second  dentition. 


than  of  the  student  or  thinker,  the  latter  being  more  often  about  seven 
and  a  half  heads  tall.  Fig,  21  is  divided  into  eighths  by  transverse 
lines,  the  middle  l)eing  marked  by  a  heavier  line.  It  will  be  noticed 
that  the  centre  of  the  vertical  diameter  falls  in  the  atlult  upon  the  pubis, 
rather  higher  in  man  than  in  woman;  in  the  newborn  it  is  rather  above 
the  navel,  and  at  intermediate  ages  at  various  intermediate  points, 
gradually  approximating  the  adult  position.  But  it  may  be  remarked 
that  many  adults  present  proportions,  owing  to  relatively  large  heads 


GROWTH  AND  HYGIENE 


73 


and  relatively  long  bodies,  not  very  different  from  that  of  the  figure 
given  as  proper  to  the  age  of  fifteen  years. 

The  head  of  the  newborn  child  is  two-eighths,  or  one-fourth,  of  its 
height,  twice  the  adult  proportion.  The  trunk  is  as  long  as  the  inferior 
extremities.  In  Fig.  21  the  five  standing  figures  are  drawn  as  of  equal 
height,  which  shows  the  relatively  heavy  proportions  of  the  infant.  The 
small  crossed  circles  on  the  vertical  diameter  of  each  figure  mark  the 


Fig 

23 

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Chart  showing  height  anii  weight. 


head  heights  for  that  figure.  I  have  calculated  that  a  man  of  five  feet 
and  ten  inches,  built  on  the  lines  of  an  average  infant,  would  weigh  at 
least  three  hundred  pounds. 

It  will  also  be  noted  that  while  the  lower  extremity  is  longer  than  the 
upper  in  the  adult,  the  reverse  is  true  in  the  newborn  and  gives  to  the 
latter  a  suggestion  of  simian  build.  In  actual  growth  from  birth  to 
the  stature  of  nearly  six  feet  the  height  of  the  head  nearly  doubles, 
that  of  the  chest  trebles,  the  length  of  the  upper  extremity  quadruples, 
and  that  of  the  lower  extremity  reaches  five  times  its  length  at  birth. 


74 


DEVELOPMEST,   GROWTH  ASD  HYGIENE 


The  proportions  just  given  are  in  round  numbers.     Vierordt*  fjues 
the  followini'  table  as  the  resuH  of  various  measurements.    The  100  in 


Fig 

2- 

5  J 

AGE  BY  YEARS 

1  3  3  4  5  0  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23 

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Chart  showing  height  in  inches. 
1  Gerbardt's  Kindk  ,  i.  82. 


GROWTH  AND  HYGIENE  75 

the  first  column  represents  the  average  length  of  that  part  in  the 
newborn,  the  other  figures  represent  the  relative  length  or  height  of 
that  part  at  the  various  ages  until  adult  stature  is  reached. 

End  of  Seven  and 

Part.                                   Newborn,  twenty-first  one-eighth         Adult. 

month.  year. 

Height  of  head 100  150  191.7  200 

Cranial  part  of  head 100  114  150  157 

Face 100  200  250  260 

Chin  to  manubrium 100  500  700  000 

Sternum 100  18G  300  314 

Abdomen 100  160  240  260 

Inferior  extremity 100  200  455  472 

Height  of  foot 100  150  300  450 

Arm 100  183  328  350 

Forearm 100  182  322  350 

That  this  growth  is  not  uniform  is  well  known  and  its  curve  when 
charted  presents  neither  a  straight  line  nor  any  uniform  curve.  If  the 
number  of  observations  be  large  the  line  will  be  a  wavy  one  (Fig.  23), 
but  if  a  single  case  be  chosen  and  frecjuent  observations  be  made,  the 
variations  may  be  still  more  striking  (Fig.  24).  Similar  irregularity 
exists  in  the  increase  in  weight,  but  the  curves  of  the  weight  line  are 
not  identical  "^ith  those  of  the  stature  line,  as  will  presently  be  pointed 
out  more  particularly.  It  may  be  mentioned  here  that  these  irregular- 
ities are  more  evident  the  more  frequently  observations  are  made. 
Thus,  if  measurements  be  made  on  rising  and  retiring  it  becomes 
evident  that  children  are  taller  in  the  morning  than  at  night,  not  neces- 
sarily tliat  they  grow  more  at  night,  but  rather  from  the  compression 
of  the  elastic  cartilages  by  the  body  weight  during  the  day.  On  the 
contrary,  the  weight  is  least  on  rising  and  increases  during  the  day. 
But  this  is  doubtless  due  to  fasting,  alternating  with  ingestion  of  food 
and  drink.  More  strildng,  because  relieved  of  these  complicating 
causes,  is  the  observation,  made  in  a  considerable  number  of  children 
in  an  instituton,  but  which  agrees  fairly  well  with  my  experience,  that 
the  periods  of  increase  in  stature  and  in  weight  are  not  synchronous. 
The  maximum  of  growth  in  stature  is  between  March  and  the  beginning 
of  August,  \A\\\e  the  maximum  increase  in  weight  is  between  the  end  of 
August  and  December.  The  maximum  of  stature  increase  corresponds 
with  the  minimum  of  weight  increase  and  vice  versa.  So  that  the 
progress  is  alternating.  It  may  be  as  yet  unsafe  to  take  these  obser- 
vations as  the  basis  of  definite  assertions,  but  further  ones  are  well 
worth  the  making. 

Besides  these  daily  and  seasonal  variations,  it  is  a  matter  of  daily 
observation  that  there  are  longer  periods  in  which  the  asymmetry  of 
stature  and  weight  increase  are  pronounced;  those  periods,  namely,  of 
alternate  rotundity  and  slenderness  which  are  called  in  nursery  parlance 
"rounding  out"  and  "running  up,"  or  "weediness,"  to  which  attention 
has  been  attracted  by  scientific  measurements  and  tabulation. 

If  a  single  case  be  charted  this  discrepancy  between  the  curves  of 
stature  and  weight  may  be  quite  striking.  In  a  large  number  of  cases, 
as  the  time  of  the  changes  vary  a  little  all  along  the  line,  the  sharpness 


76  DFAEI.OPMEXT,   GROWTH   AND  HYGIEXE 

of  the  curves  is  softened,  as  in  a  composite  photoi^raph.  Nevertheless, 
as  seen  in  Y'\g.  24,  the  general  tendency  can  be  noted  by  the  tlivergence 
of  the  line  of  growth  in  height  from  the  line  of  increavse  in  weight.  It 
will  be  noticed  that  l)etween,  say,  five  years  and  eight  years  the  rise 
in  the  weight  curve  is  particularly  small,  while  that  in  the  height  curve 
is  rapid.  The  second  period  of  "stretching  up"  occurs  somewhere 
between  eleven  and  fifteen  years.  The  relatively  smaller  increase  in 
weight  is  less  well  marked  in  the  curves  than  in  the  earlier  period  just 
mentioned.  These  alternatives  of  plumpness  and  elongation  are  fairly 
well  represented  in  Fig.  22. 

Returning  to  Fig.  24,  it  will  be  noticed  that  tlie  lines,  solid  and  broken, 
do  not  continue  roughly  parallel,  but  cross  and  recross.  In  other  words, 
from  birth  until  the  twelfth  year  boys  on  the  average  are  both  taller 
and  heavier  than  girls.  IJut  at  the  latter  age  girls  pass  the  boys  and 
continue  taller  for  about  three  years,  while  they  are  heavier  than  boys 
for  still  another  year.  This  period  of  superiority  of  stature  and  weight 
on  the  part  of  girls  has  been  noted,  I  believe,  by  all  observers,  and 
is,  therefore,  a  universal  phenomenon.  The  relative  plumpness  and 
slenderness  exhil)ited  in  Fig.  22  is  expressed  scientifically  by  the  pro- 
portion of  weight  to  height,  a  proportion  which,  of  course,  must  diminish 
as  the  frame  changes  through  the  stages  shown  in  Fig.  21.  But  the 
weight-height  ratio  for  a  given  height  will  vary  between  the  sexes,  and 
boys  appear  to  be  heavier  for  a  given  height  up  to  a])0ut  1.473  m. 
(58  in.),  when  girls  become  the  heavier.  This  dift'erence  in  the  ratio 
is  probably  not  due  to  differences  of  fat  or  development  of  other  tissues, 
but  to  the  different  proportions  between  the  trunk  and  extremities, 
which  differ  in  the  two  sexes  and  at  different  ages.  Thus  for  the  first 
ten  years  the  body  of  boys  is  longer  than  that  of  girls,  from  ten  to  sixteen 
years  the  body  of  girls  is  longer.  After  fifteen  there  is  little  increase  in 
length  of  the  body  for  girls,  while  that  of  boys  is  considerable,  often  as 
much  as  four  inches.  Of  course,  the  longer  the  body  in  proportion  to 
the  total  height  the  greater  will  be  the  weight  for  that  height.  Similar 
variations  are  noticed  in  the  relative  length  of  the  lower  extremities  in 
the  two  sexes,  these  variations  being  in  a  general  way  conversely  to 
those  already  noted  for  the  body.  But  after  fourteen  years  of  age  the 
lower  extremities  of  girls  nearly  stop  growing,  while  those  of  boys  gain 
very  much,  often  as  much  as  four  inches. 

But  Fig.  2'i  gives  not  only  relative  but  actual  results.  From  the  age 
of  five  years  to  that  of  eighteen  the  curves  are  copied  from  Bowditch. 
They  represent  the  results  obtained  from  measurements  of  24,505 
children  in  the  public  schools  of  Boston,  irrespective  of  nationality. 
The  curve  from  birth  to  four  years  is  constructed  from  figures  given 
by  Holt  as  the  result  of  measurements  of  his  own,  covering  about  500 
observations.  Throughout  the  table,  both  for  height  and  weight,  the 
solid  line  stands  for  boys,  the  broken  line  for  girls.  The  average  height 
of  a  boy  or  girl  of  any  age  can  be  approximated  by  noting  where  the 
curve  crosses  the  vertical  line  for  that  age.  The  nearest  horizontal  line 
followed  to  the  lc]t  will  give  the  height  in  spaces  of  two  inches.     For 


GROWTH  AND   HYGIENE  77 

weight  take  the  lower  curves  in  the  same  way.  The  horizontal  lines 
followed  to  the  right  will  give  the  weight  in  blocks  of  ten  pounds  each. 

The  curves  of  Bowditch  have  been  selected  out  of  many,  not  because 
they  are  absolute  for  all  children,  but  because  his  data  were  more  exten- 
sive and  more  completely  worked  out  than  those  of  any  other  of  nearly 
equal  extent,  and  the  variations  from  them  noted  by  other  observers 
can  be  easily  alluded  to. 

Thus  if  in  Bowditch 's  own  tables  special  classes  be  compared  with 
the  whole,  differences  at  once  appear.  Children  of  American  parentage 
show  rather  greater  height  and  weight  (and,  according  to  some  observers, 
greater  sitting  height,  that  is  to  say  greater  body  length  as  well)  than 
the  general  average.  When  observations  were  made  upon  the  pupils  of 
certain  selected  schools,  such  as  the  Boston  Latin  School,  the  Institute 
of  Technology,  and  some  private  schools,  the  height  and  weight  showed 
a  still  greater  increase  above  the  average  of  pupils  of  the  same  age  in  the 
general  mass  of  observations.  So,  also,  the  children  of  non-laboring 
parents  show  greater  height  and  weight  than  those  of  the  laboring 
classes. 

The  influence  of  race,  of  better  nutrition  and  hygiene  in  all  respects 
on  the  side  of  the  "comfortable"  classes  at  once  comes  to  mind,  and  to 
a  certain  degree  the  influence  of  these  agencies  is  undoubted.  But 
one  cannot  go  far  in  the  study  of  recorded  observations  without  finding 
many  other  agencies  which  are  operative  and  noting  variations  for 
which  the  cause  is  not  yet  evident.  Confining  ourselves  to  statistics 
taken  in  our  own  country,  we  notice  considerable  difference  in  the 
average  of  height,  for  instance,  and  this  difference  does  not  seem  to  be 
governed  by  section  or  climate,  nor  to  depend  upon  racial  or  social 
distinctions  so  far  as  reported.  Thus  taking  the  highest  average  first 
and  ending  with  the  least  the  order  is  Pennsylvania;  lov/a;  New  Haven, 
Conn.;  Worcester,  Mass.;  Oakland,  Cal.;  Milwaukee;  Boston;  St. 
Louis,  an  order  not  agreeing  with  any  preconceptions  based  upon 
general  information.  The  tallest  group  in  this  list  is  about  the  equiva- 
lent of  one  year  in  advance  of  the  last  as  regards  stature.  Taking  all 
these  groups  together,  Boas  worked  out  mathematically  a  table  for  the 
"average  American"  which  gives  a  curve  averaging  about  one-third 
of  an  inch  higher  than  that  shown  in  Fig.  23.  The  practitioner  rarely 
can  gather  anywhere  statistics  which  will  give  this  "average"  value. 
Drs.  Gould  and  Baxter  observed  that  migration  from  east  to  west 
seemed  attended  by  an  increase  of  average  stature.  Whether  this  was 
due  merely  to  the  migration  to  different  climatic  and  geographical  sur- 
roundings, as  is  suggested  by  the  fact  that  the  increased  stature  of  the 
newcomers  is  assimilated  to  that  of  the  earlier  residents,  or  whether  im- 
proved conditions  of  living  and  the  fact  that  in  migration,  as  in  early 
immigration,  the  migrants  are  usually  in  a  way  picked  individuals  who 
live  in  the  open  air,  contribute  to  the  results  is  uncertain.  Another 
striking  fact  was  elicited  by  these  observers — namely,  that  there  is  a 
slow  increase  of  stature  until  the  age  of  thirty-five  years. 

The  most  noticeable  part  of  a  growth  curve,  after  the  sudden  rise  of 


78  DEVELOPMENT,   GROWTH   AM)   HYCIESE 

the  first  two  or,  perhaps,  three  or  four  years,  is  the  rise  wliich  marks 
the  puberal  or,  as  it  often  is,  prej)ul)eral  »;rowtli.  The  eurve  in  the 
figure  is  much  less  marked  for  stature  than  for  weight.  But,  as  already 
said,  in  both  it  is  rounded  off  from  the  fact  that  this  growth  is  so  widely 
distributed  in  different  eases.  Thus  we  see  children,  especially  girls,  who 
have  nearly  or  (juite  reached  their  adult  stature  at  twelve  years.  (See 
Fig.  23,  lower  curve.)  On  the  other  hand,  it  is  not  rare  to  find  women 
who  have  grown  materially  after  marriage,  say  between  eighteen  and 
twenty  years  of  age;  and  I  have  by  me  the  chart  of  a  youth  w'lio,  having 
been  below  tlie  average  until  sixteen,  then  passed  it  and  l)etween  nineteen 
and  twenty-one  gained  12.70  cm.  (five  inches),  and  still  another  5. OS  cm. 
(two  inches)  after  his  majority.  It  is  a  matter  of  common  observation 
that  the  early  beginning  of  this  puberal  growth  is  not  an  indication  that  the 
completed  stature  will  be  notably  great,  nor  is  its  delay  to  be  necessarily 
interpreted  in  the  contrary  way.  For  instance,  among  my  memoranda 
is  one  of  two  sisters  whose  adult  height  is  the  same,  but  one  attained 
it  at  twelve  years,  the  other  at  sixteen.  It  is  interesting  to  note  that 
however  much  this  growth  may  be  retarded  by  illness,  by  adverse 
circumstances,  or  by  unknown  causes,  the  process  is  resumed  with  the 
greatest  pertinacity  again  and  again.  So  that  some  observers  have  been 
inclined  to  believe  that  there  is  for  each  individual  a  certain  ultimum 
of  stature,  predetermined  in  some  way,  perhaps  by  its  own  tissue 
structure,  toward  which  the  organism  struggles  and  at  which  it  nearly, 
if  not  quite,  finally  arrives.  Such  a  theory  cannot  now  be  proved  or 
disproved,  but  the  student  of  the  laws  of  growth  sees  much  of  (Micourage- 
ment  in  this  persistence  of  the  organism  in  achievement  of  a  reasonable 
stature  under  circumstances  seemingly  most  adverse,  even  if  he  must 
also  admit  that  no  one  "by  taking  thought  can  add  one  cubit  unto  his 
statur(\" 

Space  forbids  any  discussion  of  t'ne  exceptionable  stature  noted  of 
recent  years,  especially  among  women.  I  have  for  some  years  been 
seeking  to  find  in  stock,  in  habits,  in  hygiene,  and  along  all  the  usual 
avenues  of  in(|uiry  to  find  an  ex])lanation  for  the  phenomenon,  but  I 
have  failed  to  find  one  at  all  satisfactory. 

Some  discussion  has  arisen  over  the  claim  that  children  who  are 
large  for  a  given  age  are  also  forward,  as  evinced  by  school  grade,  for 
that  age.  Everyone  can  call  to  UTintl  cases  showing  the  contrary  in 
both  senses.  Yet,  while  nothing  can  be  predicted  in  advance  regarding 
any  given  individual,  statistics  of  large  numbers  of  school  children  seem 
to  show  that  there  is  a  general  correlation  between  good  bodily  nutrition 
and  mental  development. 

Boas  has  stated  that  he  found  that  of  children  above  six  years  of  age 
the  first-born  children  are  both  taller  and  heavier  than  later  children. 
I  have  no  statistics  liearing  upon  this  point  during  the  growing  years. 
But  as  regards  the  completed  growth  of  the  different  children  in  families 
my  experience  is  quite  the  opposite.  Possibly  different  conditions  may 
account  for  the  <lif^*erent  findings.  Thus,  if  public-school  children  are 
observed,  it  is  possible  that  they  come  in  a  considerable  proportion 


GROWTH  AND  HYGIENE  79 

from  families  where  frequent  pregnancies  and  difficult  household  con- 
ditions may  have  diminished  the  mother's  vitality  jpari  fassu.  In  the 
"comfortable"  classes,  whence  my  observations  are  drawn,  these 
influences  have  not  been  operative,  and  the  improving  intelligence  of 
the  mother  as  regards  hygienic  matters,  both  for  herself  and  progressively 
for  her  children,  has  doubtless  been  beneficial  to  the  latter.  Besides,  it 
has  been  asserted  as  a  result  of  considerable  observation  that  the  pro- 
portion of  the  weight  of  the  newborn  to  that  of  the  mother  increases 
with  the  number  of  pregnancies,  and  there  is  no  evidence  that  these 
heavier  children  do  not  hold  their  own  with  the  lighter  ones  unless  the 
mother's  milk  fails. 

THE  NURSERY. 

The  nursery  should  be  arranged  for  l)efore  the  delivery,  and  if  the 
accoucheur  be  the  family  physician,  he  can  do  much  by  judicious  advice 
to  make  a  hygienic  place  for  the  infant.  This  he  is  bound  to  try  to  do, 
inasmuch  as  the  susceptibility  of  a  child  to  the  depressing  influences 
of  bad  hygiene  is  conversely  to  its  age,  the  baby  suffering  more  than 
the  child,  the  child  more  than  the  half-grown  or  adolescent.  The 
nursery,  therefore,  ought  to  be  the  most  wholesome  room  of  the  house 
or  tenement.  Given  a  fairly  healthful  home,  it  is  not  difficult  to  make 
a  wholesome  nursery.  Well-to-do  people  often  indulge  in  expense  or 
lavishness  for  the  nursery,  but  often  from  want  of  knowledge  this  goes 
for  luxuries  rather  than  necessities.  The  necessary  expense  is  not  great 
if  it  be  borne  in  mind  that  the  essentials  are  sunshine,  pure  air,  dryness, 
suitable  warmth,  and  always  cleanliness.  The  first  three  desiderata  are 
easier  gained  on  an  upper  floor,  but  that  next  the  roof  is  usually  too 
susceptible  to  external  fluctuations  of  temperature.  Even  in  summer  a 
sunny  room  is  more  wholesome  than  an  unsunned  one.  Morning  sun, 
if  it  can  be  had,  is  preferable  to  afternoon  sun. 

Heating. — The  method  of  heating  the  nursery  is  in  towns  usually  pre- 
determined by  the  construction  of  the  house.  Of  the  various  forms  of 
furnace-made  v/armth  I  prefer  that  of  hot  water,  on  the  ground  that  it 
yields  a  uniform  temperature  more  easily  than  other  methods.  The 
supply  of  cold  air  nuist  be  from  an  uncontaminated  source,  and  the 
physician  would  do  well  to  assure  himself  that  this  is  such.  The  intake 
air  pipes  must  be  high  from  the  ground,  the  mouths  reversed  and 
screened  to  prevent  things  from  falling,  and  animals  and  insects  from 
crawling  into  them. 

A  large  amount  of  moderately  heated  air  is  preferable  to  a  small 
amount  of  very  hot  air,  because  it  introduces  a  larger  volume  of  fresh 
air  and  is  less  provocative  of  draughts. 

The  temperature  of  the  nursery  is  usually  too  high.  If  children  of 
various  ages  must — as  is  usually  the  case — occupy  the  nursery,  the 
requirements  of  the  youngest  (and  probably  the  feeblest)  have  to  be 
taken  for  a  guide.  Most  American  writers  set  70°  F.  as  the  desired  temper- 
ature.   In  England  probably  65°  F.  would  be  better  approved.    Probably 


80  DEVl'JLOPMi:.\T,   (IROWTIl   AM)   IIYaiEM'J 

70°  F.  is  as  niodcnite  a  (i<furo  as  can  he  hoped  for  in  our  usually  over- 
warm,  furnaee-heated  homes,  and  if  children  are  old  enough  to  go 
about  the  house  or  into  other  homes,  which  are  sure  to  be  overheated, 
it  is  often  more  prudent  to  keep  the  nursery  above  the  ideal  heat  than 
to  subject  the  children  to  frecjuent  variations.  I,  however,  feel  sure 
that  healthy  children  will,  other  things  being  equal,  be  comfortable  and 
will  be  more  likely  to  remain  cpiite  well  in  a  nursery  kept  steadily  at  ()5°  F. 
than  in  one  at  70°  F.,  and  certainly  than  in  one  at  a  higher  temperature. 
If  there  are  very  young  children  in  the  mu'sery  the  night  warmth  must 
be  kej)t  U]).  If  ibe  situation  of  the  hot-air  registers  is  not  already  detc>r- 
miued,  they  would  better  be  placed  high  above  the  floor,  since  thus 
placed  they  conduce  to  a  better  mingling  of  the  air  and  are  but  of  the 
way  of  chilflish  meddling.  The  open  tire  is  an  excellent  adjunct  to  the 
furnace  in  severe  weather,  but  it  is  not  desiral)le  in  mild  weather  unless 
the  furnace  can  be  correspondingly  controlled. 

If  there  is  no  furnace  the  choice  of  heating  mechanism  lies  between 
the  open  fire,  Fraiddins  in  their  various  forms,  stoves  more  or  less 
"air-tight,"  and  "heaters."  The  advantages  of  the  open  fire  are  its 
cheerfuln(\ss  and  its  ventilating  value;  its  disadvantages,  its  vvastefuhiess 
of  fuel  and  the  uneciual  warming  of  the  a])artment.  The  Franklins 
diminish  the  waste  of  fuel, and  to  a  less  degree,  owing  to  their  construction 
and  placing,  lessen  the  ine({uality  of  heating.  Stoves  are  economical  of 
fuel,  give  a  large  amount  of  heat,  and  practically  no  ventilation  of  them- 
selves. By  "heaters"  is  meant  a  sort  of  stove  heating  the  room  in 
wliich  it  is  placed  and,  by  means  of  a  register,  that  above.  They  have 
a  little  of  the  convenience  of  a  furnace,  with  the  objection  that  as  usually 
arranged  the  air  sent  to  the  upper  room  has  been  drawn  from  the  lower, 
and  is  probably  already  vitiated  by  the  occupants  and  lights  of  that 
lower  room.  Obviously  a  nursery  should  not  be  supplied  with  second- 
hand air.  Gas  stoves  for  nursery  use  need  only  be  mentioned  for 
condemnation.  They  not  only  have  no  ventilating  power,  but  throw 
their  combustion  products,  not  into  a  chimney,  but  into  tlie  breathable 
air.  This,  of  course,  does  not  aj^ply  to  "gas  logs"  set  into  fireplaces 
with  flues,  but  it  does  ecjually  apply  to  oil  stoves  of  all  sorts  burning 
in  the  ojjcn  room  and  without  escape  flues. 

Ventilation. — This  is  the  proper  place  to  speak  of  the  effect  of  lights  in 
vitiating  air.  A  common  candle  produces  nearly  as  much  carlionic  aci«l 
(carlK)n  dioxide)  as  an  average  adult,  a  large  kerosene  lamp  or  gas  burner 
sometimes  as  much  as  five  or  six  persons.  It  is  easy  to  estimate  tb.e 
effect  of  several  Hghts.  If  a  night  light  be  required  it  should  be  as 
small  as  practicable  and  placed  if  possible  beneath  a  ventilating  opening 
or  in  the  fire|)lace,  so  that  its  combustion,  gases  may  escape  up  the 
chimney  and  assist  the  draught  from  the  room.  One  thousand  feet  of 
air  space  are  desirable  for  an  infant,  but  few  rooms  can  give  this  amount 
if  an  attendant  occuj)ies  the  nursery  with  it,  to  say  nothing  of  other 
children.  We  must  accommodate  our  deman<ls  to  the  possibilities. 
The  best  sun-lighted  room,  already  described,  must  be  chosen  and  the 
air  frequently  renewed.     While  many  houses  have  heating  plants,  few 


GROWTH  AND  HYGIENE  gj 

have  definite  ventilating  facilities.  Probably  from  convenience  the 
heating  apparatus  has  come  in  many,  perhaps  most,  houses  to  do  the 
work  of  ventilation  as  well.  The  open  fireplace  makes  an  excellent  base 
ventilator,  but  it  may  also  make  very  uncomfortable  and  even  dangerous 
floor  draughts,  if  the  fresh  air  enters  at  low  levels.  This  latter  point 
becomes  important  as  soon  as  children  are  old  enough  to  play  upon  the 
floor,  and  therefore  the  air  should,  if  practicable,  be  admitted  at  points 
sufficiently  above  the  floor  to  permit  its  admixture  with  the  air  of  the 
room  which  it  is  intended  to  purify. 

If  there  is  no  open  fireplace,  ventilating  flues  opening  near  the  floor 
may  be  carried  up  to  a  convenient  height  and  then  into  a  chimney  flue, 
the  draught  of  which  by  suction  helps  to  clear  out  the  low-lying  foul  air 
of  the  room.  This  may  be  done  in  several  ways,  but  the  principle  is 
one.  A  ventilating  flue  to  the  roof,  the  vent  being  capped,  solves  the 
same  problem.  If  a  stove  be  the  source  of  heat,  the  ventilating  flue 
will  be  more  efficient  if  it  be  near  enough  to  the  stove  to  have  its  air 
column  warmed  by  the  latter. 

If  no  flue  can  be  utilized,  the  various  window  boards — those  with 
whirligigs,  those  with  elbow  tubes,  or  simple  boards — will  serve  to  let 
in  air,  and  the  latter  can  be  contrived  to  also  let  out  air.  Air  may  enter 
at  the  foot  of  the  raised  sash,  behind  the  window  board,  and  may  enter 
or  leave  by  the  aperture  caused  by  the  overlapping  of  the  lower  sash  upon 
the  upper  one.  A  stout,  closely  woven  cloth  may  be  nailed  across  the 
lower  part  of  the  window  and  serve  the  same  purpose  as  the  board. 
Besides  being  avenues  of  ingress  and  egress  for  air,  windows  are  great 
modifiers  of  the  temperature  of  a  room.  Here  is  the  formula:  Each 
square  foot  of  glass  will  cliill  (or,  in  hot  weather,  warm)  1.279  cubic 
feet  of  air  each  minute  as  many  degrees  as  the  dift'erence  between  the 
inside  and  outside  temperature.  It  is  easy  to  figure  out  the  effect  upon 
any  particular  room.  The  result  is,  in  cold  weather,  that  the  neighbor- 
hood of  a  window  is  a  frigid  zone.  It  is  best  to  place  across  the  front  of 
nursing  windows  articles  of  furniture  w4iich  will  keep  young  children 
away  from  this  immediate  neighborhood. 

The  ordinary  elements  of  dryness  in  a  house,  good  drainage,  dry 
cellars,  etc.,  need  no  comment.  Some  personal  experience  leads  me 
to  insist  that  trees  near  a  house  are  not  desirable.  They  obstruct  sun- 
shine and  retain  moisture.  Their  function  as  ornaments  and  as  wind- 
breakers  is  best  performed  if  they  stand  far  enough  from  the  house  to 
allow  free  circulation  of  air  and  abundant  sunshine. 

Cleanliness  in  the  nursery  is  rather  exacting,  as  the  room  may  at  any 
moment  become  a  sick-bay.  It  demands  a  tight,  easily  cleansed  floor, 
rugs  or  light  carpet  squares  which  can  be  taken  out-of-doors  frequently 
and  not  swept  m  situ — in  other  words,  the  dirt  must  be  removed,  not 
simply  stirred  up.  The  walls  are  better  painted  than  papered,  and 
should  be  as  little  encumbered  as  possible.  Window  drapery  should  be 
very  simple;  shades  and  blinds  are  alone  desirable,  and  stuff  hang- 
ings are  particularly  objectionable.  Furniture  should  likewise  be 
chosen  with  reference  to  the  possibility  of  keeping  it  clean.  Painted 
6 


82  DEVEI.OI'MEXr,    aiiOWTII   A.\D   CYCIESE 

iron  bedsteads  and  wash-stands  seem  best  to  meet  tlie  needs.  The  cril) 
lor  the  lial^y  slunild  be  high  enoui^h  from  the  floor  to  eseajx'  (h'au<i;ht, 
and  it  should  not  be  covered  with  (h'aperynor  phieed  in  a  corner  of  tlie 
room.  If  away  from  the  wall  it  will  be  easier  to  care  for  the  bai)y  and 
the  air  will  be  better.  Cupboards  and  closets,  bureaus  and  wardrobes 
are  constant  pitfalls  for  the  household  hygienist.  Were  it  not  for  the 
terrors  of  "sweeping  day,"  I  would  take  off  the  doors  from  all  mu'sery 
closets  so  that  everything  in  them,  hanging  or  on  shelves,  could  be  at 
once  seen  to  be  in  order,  and  would  be  easily  and  constantly  aired. 
Plumbing  in  the  nursery  is  another  source  of  untidiness  antl  sometimes 
of  risk.  The  toilet  facilities  should  be,  if  in  the  room  at  all,  the  simple 
bowl  and  'pitclier.  Nor  should  the  V)ath-room  and  water-closet  be 
immediately  connected  with  nor  too  nearly  adjacent  to  the  nursery. 
The  nursery  adviser  must  keep  in  mind  the  welfare  of  the  child,  not 
the  ease  of  the  attendant. 

If  food  is  to  be  prepared  in  the  nursery,  absolute  cleanliness  is  recjuired 
in  all  details,  but  it  will  be  better  to  keep  all  food  in  an  adjoining  room. 
The  air  of  the  nursery  should  never  be  contaminated  by  soiled  diai)ers 
and  clothing,  nor  should  the  nursery  be  used  as  a  drying  room. 

The  care  of  newborn  and  of  premature  infants  having  been  treated  in 
Chapter  I.,  we  pass  here  directly  to  "  Nursery  Routine." 

Nursery  Routine. — ^^rhe  care  of  the  newborn  infant  imj>erceptibly 
changes  into  that  of  the  baby.  Its  baths  and  clothing  are  modified 
or  changed  as  required,  but  very  gradually.  In  the  same  manner  it 
advances  to  the  use  of  its  members  and  to  changes  of  air.  These  may 
he  spoken  of  a  little  in  detail. 

Baths. — The  bath,  after  those  necessary  for  the  complete  cleansing 
of  the  infant  after  delivery  and  after  the  cord  is  separated,  follows 
usually  a  simple  routine.  The  immersion  bath,  of  temperature  about 
100°  F.,  a  basin  of  warm  water,  bland  soap,  the  necessary  towels,  napkins 
and  cotton  and  clothing  are  arranged  in  a  warm  part  of  the  room. 
The  nurse  then,  having  on  a  thick  apron  or  a  bath  towel  adjusted  in  its 
stead,  undresses  the  infant,  wraps  it  for  warmth,  while  she  with  cotton 
or  cheese-cloth  sponges  with  soap-suds  in  all  the  parts  likely  to  be  soiled. 
This  com])leted,  the  baby  is  immersed  for  a  moment  or  two  in  its  bath. 
This  immersion  is  really  for  the  rapid  washing  away  of  the  suds  by  the 
f|uickest  method,  as  saving  fatigue  to  the  baby  as  well  as  labor  to  the 
attendant.  But  it  is  not  at  all  a  necessary  part  of  the  bathing,  nor 
should  it  be  made  a  fetish  as  it  often  is.  It  may  be  omitted  whenever 
its  administration  for  any  reason  causes  depression  or,  if  an  infant 
be  feeble,  whenever  it  be  found  that  other  methods  are  better  borne. 
Ordinarily,  a  baby  wlicn  still  very  young  enjoys  its  bath,  and,  rejoicing 
at  the  freedom  of  its  limbs,  turns  this  nursery  duty  into  a  pleasure  for 
the  admiring  mother  or  nurse.  The  bathing  of  infants  and  children 
who  are  not  under  direct  medical  care  will  he  especially  mentioned  later. 

As  infancy  progresses  the  temperature  of  the  bath  may  be  slightly 
lowered.  Rules,  of  course,  are  not  fixed,  but  only  guides.  I  have 
been  able  to  devise  no  better  general  rule  than  to  drop  this  temperature, 


GROWTH   AND  HYGIENE  83 

which  started  at  100°  F.,  about  one  degree  per  month,  the  bath  ther- 
mometer, of  course,  being  used. 

The  further  reduction  of  the  temperature  of  the  bath  after  the  first 
year  must  also  be  governed  by  circumstances.  So  long  as  the  immersion 
bath  is  continued,  its  temperature  must  be  high  enough  to  ensure  no 
depression  and  a  prompt  reaction  upon  drying  and  slight  friction. 
By  two  years  of  age,  if  not  earlier,  the  sponge  bath  may  be  substituted 
for  the  immersion.  The  temperature  may  then  be  considerably  lower. 
If  the  child  stands  in  water  of  90°  to  95°  F.  deep  enough  to  be  well  above 
its  ankles,  thus  ensuring  the  warmth  of  the  extremities,  a  sponge  bath 
of  water  twenty  degrees  below  these  figures  will  be  well  borne  by  healthy 
children  if  it  is  quickly  given,  say  in  a  minute.  This  is  the  bath  of 
regimen,  so  to  say,  making  the  child  better  able  to  meet  the  day,  while 
the  bath  for  special  cleanliness,  which  is  still  to  be  given  warm  as  often 
as  requisite,  is  best  given  just  before  the  child  is  put  into  bed  at  night. 
This  same  routine  may  be  continued  so  long  as  the  child  has  its  bath 
given  by  another  person,  the  temperature  of  the  sponging  water  being 
somewhat  lowered  and  its  duration  increased  according  to  the  complete- 
ness and  promptness  of  the  child's  reaction. 

This  last  phrase  suggests  the  only  hygienic  contraindication  of  the 
bath  for  infants  and  children  not  under  medical  care.  If  a  bath  of  any 
kind  at  any  age  causes  depression,  cold  extremities,  or  a  sense  of  chilli- 
ness after  the  rubbing  down,  there  is  evidently  an  unsuitableness  between 
the  child  and  its  bath,  the  cause  of  which  must  be  sought  out  and  the 
disproportion  corrected. 

Clothing. — The  essentials  of  clothing  are  protection  from  cold,  accom- 
plished without  burdensome  weight,  without  constriction  or  hindrance 
of  the  motions  of  any  part  of  the  body  or  of  the  extremities.  The  amount 
of  clothing,  of  course,  must  vary  with  the  season  for  a  child  who  is  taken 
out-of-doors.  The  nursery  temperature  being  usually  fairly  fixed  and 
also  not  very  different  from  the  outer  air  in  warm  weather,  it  is  better 
to  have  the  house  garments  not  too  burdensome  (not  so  warm,  that  is 
to  say,  as  to  excite  perspiration  if  the  child  is  active),  and  to  meet  lower 
out-door  temperatures  by  extra  garments  and  wraps.  The  exact  materials 
and  amoiuits  will  and  must  vary  with  localities,  according  to  temperature 
and  purchasing  facilities.  Substances  of  loose  texture,  such  as  gauzes, 
machine-knit  or  hand-knit  material,  confine  air  in  their  interstices  and 
are  better  non-conductors  of  heat  than  closer  woven  materials  of  equal 
weight.  Th6y  are  also  usually  yielding,  elastic  and  more  comfortable. 
While  by  no  means  advocating  any  system  of  undue  coddling,  I  have 
no  sympathy  whatever  with  so-called  "hardening"  methods,  which 
generally  involve  the  sacrifice  of  some  well-established  hygienic  principle 
to  a  fad  or  a  fashion  of  dress.  I  am  convinced  that  uniformity  of  pro- 
tection, so  far  as  is  consistent  with  the  free  use  of  the  limbs,  is  desirable, 
and  that,  for  instance,  for  the  prevention  of  colic  warm  stockings  are 
needed  as  well  as,  if  not  as  much  as,  warm  abdominal  covering.  Low 
necks,  short  sleeves,  bare  legs  have  therefore  no  place  in  the  clothing 
of  young  and  especially  of  feeble  children. 


84  l)E\  EUil'MEST,  Gh'OWTII   AXD  IDG'IEXE 

Tlu-  clotliint:^  of  the  new  baby  should  follow  these  general  rules: 
Flexible  materials,  in  easy  forms  without  girdles  or  waist-bands,  arranged 
to  be  removed  and  replaeed  with  the  fewest  mananivres  possible.  The 
naj)kins  should  be  of  soft  ab.>jorl)ent  materials.  Linen  is  traditional,  but 
if  new  it  is  hard  and  still",  and  old  linen  in  suffieient  (juantity  is  rarely 
obtainable.  Soft  eotton  materials,  sueh  as  stoekinet  and  birdseye,  are 
considerably  used,  and  so  far  as  I  have  observed  are  unobj(>etionable. 
The  napkin  should  not  be  needlessly  bulky,  and  pains  should  be  taken 
to  avoid  tightly  binding  the  thighs  together,  while  a  bunch  of  material 
is  placed  between  them.  Bending  of  the  femora  may  result.  I'he 
napkins  for  very  young  infants  may  be  of  cheese-cloth  and  absorbent 
cotton,  and  may  be  burned  or  destroyed,  as  they  are  inexpensive. 

While  objecting  to  waist-bands,  it  should  be  said  that  the  "band" 
of  the  new  baby  is  exce})ted  for  the  reasons  that,  save  when  used  as  a 
retaining  bandage  for  the  dressings  of  the  cord,  it  should  never  be  snug 
enough  to  exert  compression.  Its  sole  function  is  for  warmth  to  the 
trunk,  the  thorax,  and  abdomen.  In  infants  of  ordinarily  abundant  fat  it 
gives  place  after  a  few  weeks,  or  months  at  most,  to  the  knitted  shirt. 
If  it  is  made  tight  it  is  a  harmful  constriction,  and  while  probably  hinder- 
ing an  uml)ilical  or  ventral  hernia,  it  probably  favors  inguinal  hernia 
by  furnishing  a  point  of  resistance  by  which  unusual  and  even  harmful 
pressure  can  be  brought  to  bear  upon  the  inguinal  canals  if  the  infant 
cries  or  strains  very  much. 

The  needless  continuance  of  napkins  may  be  mentioned  in  connection 
with  clothing.  While  an  infant  may  need  napkins  for  a  year,  or  for 
special  reasons  even  longer,  there  is  no  doubt  that  they  are  usually 
continued  unnecessarily  long.  If  an  infant  is  very  early  accustomed  to 
have  a  small  nursery  vessel  placed  against  its  pelvic  extremity  with 
regularity  it  soon  associates  its  presence  with  the  evacuation  of  the 
bladder  or  rectum,  and  these  functions  become  regular  far  earlier  than 
would  otherwise  be  the  case.  The  trouble  necessary  to  bring  this  to 
pass  even  in  rather  difficult  cases  is  certainly  much  less  than  that  of 
caring  for  the  napkins  soiled  during  their  usually  unnecessarily  pro- 
longcil  use. 

The  need  of  night  napkins  is  also  frequently  prolonged  by  needlessly 
large  or  frecjuent  meals  of  liquid  at  night.  In  the  section  upon  Feeding 
hints  regarding  the  hours  for  night  feeding  are  given. 

One  of  the  most  obvious  errors  in  dress  and  also  one  of  the  most 
difficult  to  arrest  is  the  cramping  of  the  feet  of  young  children  in 
improperly  sha|x,'d,  especially  in  too  pointed,  shoes.  Anyone  who  has 
taken  the  trouble  to  notice  the  foot  of  a  newborn  infant  knows  that  the 
great  toe  naturally  diverges  toward  the  median  line  of  the  body,  in  a 
manner  comparable  to  the  divergence  of  the  thumb  when  tlie  hand 
is  pronated,  but,  of  course,  in  a  less  degree.  A  medical  man  sees  at 
once  the  folly  of  distorting  this  member,  Init  his  advice  is  often  dis- 
regarded because  of  tlie  greater  ease  with  which  bad  shoes  are  obtained 
than  good  ones,  and  because  of  the  tlioughtless  vanity  of  mothers.  But 
good  shoes  are  far  less  liard  to  procure  tiian  form(n-ly,  and  it  is  as  well 


GROWTH  AND  HYGIENE  85 

worth  a  physician's  thought  to  encourage  the  use  of  such  as  it  is  to 
encourage  the  use  of  spectacles  in  proper  cases. 

Air  and  Exercise. — It  is  desired  that  the  infant  should  have  the  purest 
air  obtainable,  and  ordinarily  out-door  air  is  purer  than  that  of  the 
house.  It  may,  therefore,  be  taken  out-of-doors  as  soon  as  It  can  be 
properly  protected  as  regards  warmth.  The  conditions  are  not  the 
same  in  the  country  or  in  small  villages  as  they  are  in  a  great  city,  and 
what  here  is  said  refers  to  places  not  crowded.  In  ordinary  summer 
weather,  when  the  house  is  not  artificially  heated  and  windows  are  kept 
open  much  of  the  time,  the  infant  may  be  taken  out  very  early,  as  soon 
as  its  need  of  especial  warmth  is  passed.  This  is  practically  when  it 
has  regained  the  initial  loss  in  weight  of  the  first  few  days,  say  when 
it  is  a  week  or  ten  days  old.  It  is,  of  course,  to  have  additional  wraps 
if  the  out-door  temperature  is  lower  than  that  of  the  house.  In  this 
warm  season,  when  windows  are  open,  there  is  less  gain  as  to  purity 
of  air  by  going  out-of-doors  than  at  other  times.  The  child  should  be 
accustomed  to  out-door  airing  e\  en  then,  as  establishing  the  out-door 
habit  before  cooler  weather  arrives.  Even  in  summer  the  child  should 
be  protected  from  the  wind  and  its  eyes  shielded  from  strong  sunshine. 

If  the  birth  has  occurred  in  the  spring  or  autumn,  rather  more  manage- 
ment and  circumspection  are  needed,  and  this  is  increasingly  true  if 
the  baby  comes  in  winter,  when  it  is  rare  that  a  baby  can  be  judiciously 
taken  out-of-doors  under  the  age  of  a  month,  and  this  only  in  moderate 
weather.  In  severe  winters  it  is  sometimes  very  hard  to  find  suitable 
days  for  a  very  young  baby  to  be  taken  abroad.  The  warm  part  of  the 
day  must  be  chosen,  and  sunny,  sheltered  nooks  be  sought  for.  I 
believe  also  that  it  is  safer  to  take  quite  young  children  in  the  arms, 
not  in  the  baby  carriages.  They  thus  get  the  warmth  and  support  of  the 
attendant's  body,  and  the  child's  wraps  must  be  arranged  not  for 
display  of  embroidery,  but  for  the  best  protection  of  its  body  and  extrem- 
ities. The  airing  must  be  brief,  say  a  quarter  of  an  hour  at  first,  and 
this  time  prolonged  gradually  as  its  effect  is  noted.  If  a  baby  has  gotten 
a  good  start  in  the  warm  season  it  is  easy  to  keep  it  out  daily  an  hour  or 
two  as  the  cooler  season  advances,  with  the  protection  of  the  baby 
carriage,  wraps,  and  foot-warmers.  Thus  safeguarded  they  may  get 
the  air  or  even  sleep  out-of-doors  without  harm. 

In  great  towns,  save  for  those  living  very  near  to  parks  or  open  spaces, 
the  problem  of  airing  is  less  simple.  One  who  walks  the  main  streets 
of  a  residence  district  sees  a  good  many  objectionable  features  as  to  the 
airing  of  babies,  and  more  especially  of  young  children.  The  baby 
carriages  are  often  massed  in  great  numbers,  proceeding  more  in  accord- 
ance with  the  conversational  fancies  of  the  nursery  maids  than  with 
regard  to  the  protection  of  the  children's  eyes  from  sun  or  their  air 
passages  from  dust  and  dirt.  In  fact,  this  latter  is  often  impracticable 
when  upon  every  block  buildings  are  coming  down  or  going  up  and 
the  street  dirt  of  all  sorts  is  blown  about  by  the  wind  forced  along 
narrow  streets  flanked  with  high  buildings.  The  older  children  who  are 
not  in  carriages,  but  who  solemnly  walk  along  beside  the  carriages,  are 


86  DEVELOPMENT,   GROWTH  AND  HYGIENE 

even  less  well  protected.  In  cities  which  are  not  well  tuid  constantly 
cleaned  the  nntidy  <!;utters  still  fnrther  deteriorate  the  air. 

Under  snch  circumstances,  many  years  ago,  1  adopted  the  ])lan  of 
in-door  airings;  that  is  to  say,  of  opening  widely  the  windows  of  a  sunny 
room  as  high  up  as  practicable,  so  as  to  avoid  as  far  as  possible  the 
gutter  and  sewer  emanations,  and  let  the  children,  dressed  for  the  street, 
play  in  this  room,  the  windows  b(>ing  adjusted,  while  the  children  are 
in  it,  so  that  they  shall  not  be  imj)r()perly  j)laced  in  draughts. 

Infants  in  ordinary  health  will  get  all  the  necessary  exercise  if  their 
limbs  are  free  from  restraint,  kicking,  rolling  about  and,  as  they  gain 
the  use  of  limbs,  in  grasping  objects,  in  creeping,  and  finally  in  walking. 
So,  later,  as  young  children,  they  will  get  in  play  all  the  necessary 
muscular  exercise;  and  if  this  can  be  taken  in  free  air,  so  much  the  better. 
One  of  the  advantages  of  the  plan  of  in-door  airing,  just  described,  is 
that  children  who  are  too  young  to  play  upon  damp  or  icy  ground  may 
play  in  a  cold,  well-aired  room.  If  the  airing  were  out-of-doors  the 
child  would  of  necessity  be  in  a  baby  carriage. 

In  the  country  the  question  of  exercise  scarcely  arises  for  children 
who  are  not  ill.  In  towns  after  school  life  is  begun,  and  especially  for 
girls,  the  problems  of  out-of-door  exercise  is  not  always  an  easy  one  to 
solve,  owing  to  the  lack  of  interest  in  their  out-of-door  surroundings  to 
very  many  children.  Walking  in  streets  is  dreary,  park  facilities  are  not 
always  convenient,  and  monotonous  if  at  hand.  The  best  solution  in 
great  towns  or  cities  is  often  the  clubbing  together  of  a  number  of 
families  to  hire,  as  a  leader  in  sports  and  exercise,  an  intelligent  young 
person,  male  or  female,  who  can  interest  the  younger  ones  in  active 
play  beyond  the  power  of  the  ordinary  nursery  attendant. 

Sleep. — A  newly  born  healthy  infant  sleeps  so  large  a  part  of  the  time 
that  its  existence  might  be  described  as  sleep  interruj)ted  with  intervals 
of  feeding,  to  which  civilization  adds  the  disturbances  of  the  toilet.  It 
follows  that  if  the  food  be  proper  in  kind  and  amount  and  the  sleep 
ample,  healthy  development  is  likely  to  follow.  The  importance  of 
proper  food  for  the  infant  is  pretty  well  and  generally  understood, 
however  poorly  its  furnishing  is  carried  out;  but  the  necessity  of  good 
habits  of  sleep,  except  so  far  as  the  comfort  of  the  baby's  attendant  is 
concerned,  is  far  less  appreciated.  During  the  first  week  the  infant  may 
prefer  to  sleep  to  taking  food,  and  unless  it  be  actually  hungry  it  may 
continue  to  sleep  when  put  to  the  breast.  The  need  of  food  presently 
increases,  however,  and  as  it  develops  it  remains  awake  more.  The 
actual  number  of  waking  hours  of  a  healthy  and  comf<)rtal)le  infant  will, 
of  course,  vary  with  individuals,  probal)ly  from  six  to  eight  in  a  day  by 
the  time  it  is  six  months  old;  nor  will  it  take  much  less  sleep  at  the  end 
of  a  year.  The  more  active,  l)odily  and  mentally,  a  child  is  the  more 
hours  it  is  likely  to  desire  to  remain  awake.  But  for  this  very  reason  it 
needs  more  rest,  and  it  is  for  these  active  children — good  health  being 
assumed — that  good  sleeping  hygiene  is  most  imperative.  So  long  as 
an  infant  receives  food,  natural  or  artificial,  during  the  hours  ordinarily 
devoted  to  sleep  by  an  adult,  we  cannot  easily  divide  the  day's  sleep 


GROWTH   AND   HYGIENE  87 

and  the  night  sleep.  When,  however,  the  night  feedings  are  reduced  to 
one  or  to  none  the  routine  is  easier  to  enforce.  This  date  should  be 
when  the  child  is  about  six  months  old.  (See  section  on  Infant  Feeding.) 
But  the  physician  must  see  that  a  good  regimen  of  sleep  is  already 
well  established,  or  he  will  be  likely  to  experience  great  difficulty  when 
night  feeding  is  abandoned. 

As  has  been  already  said,  up  to  six  months  of  age  the  amount  of 
sleep  is  large,  the  hours  of  feeding,  of  a  little  play  or  attention  to  its 
surroundings  and  of  its  toilet  being  about  all  that  it  spends  awake. 
After  the  night  feeding  is  abandoned,  the  evening  sleep  until  the  feeding 
at  the  mother's  bedtime  and  the  night  sleep  together  will  make  about 
twelve  hours.  In  addition  there  will  be  two  daily  naps,  say  one  of 
two  hours  in  the  latter  part  of  the  forenoon  and  another  one  of  an  hour 
or  more  in  the  afternoon,  and  this  routine  is  likely  to  continue  during 
the  first  year  and  it  should  be  continued  as  long  as  practicable.  But 
during  the  second  year,  while  night  sleep  continues  little  abbreviated, 
the  second  nap  is  usually  not  obtained,  the  whole  day's  sleep  being 
perhaps  no  more  than  fourteen  hours.  The  day's  nap  should  be  con- 
tinued just  as  long  as  possible,  and  if  a  child  is  no  longer  able  to  sleep 
in  the  daytime  a  period  of  rest  in  the  crib  with  the  shoes  removed  and 
the  dress  loosened,  if  not  removed,  is  of  great  advantage,  especially  as 
a  restorative  to  the  nervous  system.  The  amount  of  sleep  required  as 
children  increase  in  age  gradually  diminishes,  but  until  the  growth  is 
quite  complete  they  should  have  a  larger  amount  than  an  adult,  and 
it  is  better  that  they  should  take  all  that  the  pressing  demands  of  school 
life  allow.  Even  after  twelve  years  of  age  ten  hours  of  sleep  should  be 
aimed  at,  nor  should  this  amount  be  much  curtailed  before  sixteen. 

Good  habits  of  sleeping  are  often  already  established  by  the  monthly 
nurse  if  she  be  judicious.  The  conditions  conducive  to  quiet  sleep  are 
comfort  of  body  and  quiet  surroundings.  The  child  must  be  free  from 
constriction  or  irritation  from  its  clothing,  must  be  thoroughly  warm,  but 
not  burdened  nor  overheated  by  its  coverings,  should  have  a  comfortably 
full  but  not  overdistended  stomach,  and  its  bowels  not  constipated. 
If,  then,  it  be  placed  in  its  bed  in  a  quiet  and  dimly  lighted  room  it  is 
pretty  certain  to  sleep  unless  it  has  been  taught  some  disturbing  habit. 
If  it  has  been  put  to  sleep  by  rocking,  by  holding  in  arms  or  by  any 
similar  method  it  will  not  always  relish  being  laid  down.  If  it  is  put 
to  sleep  in  a  stuffy,  overheated  apartment,  or  in  one  (pity  that  it  need 
be  mentioned)  filled  with  the  smoke  of  the  admiring  father's  pipe  or 
cigar,  it  can  hardly  be  expected  to  rest  well.  Nor  if  it  has  been  dandled 
and  played  with  until  it  has  become  excited  can  it  compose  its  exalted 
nerves  at  once.  Whenever  one  familiar  with  infants  hears  of  restlessness 
at  night  he  pretty  certainly  inquires  concerning  the  night  meal.  If  the 
infant  be  upon  the  breast,  he  will  suspect  a  failing  milk  supply.  Many 
such  an  infant  is  promptly  cured  by  a  bottle  of  proper  food.  On  the  other 
hand,  with  bottle-fed  children  the  first  inquiry  is  regarding  an  excess  of 
food.  The  stopping  of  the  last  bottle  and  the  readjustment  of  the  day's 
routine  of  feeding  often  brings  quick  relief. 


SECTION  III. 
INFANT  FEEDING. 

By  THOMAS  S.  SOUTHWORTH,  M.D. 


CHAPTER  VI. 

MATERNAL  FEEDING— WEANING. 
MATERNAL  FEEDING. 

The  milk  of  each  mammalian  species  is  especially  adapted  to  the 
needs  of  its  young.  It  is  so  constituted  as  not  only  to  nourish  and 
furnish  the  requisite  elements  for  growth,  but,  by  a  delicate  adaptation 
to  the  digestive  organs  of  the  young,  to  gradually  develop  these  for  the 
task  of  digesting  the  kinds  of  food  upon  which  it  will  subsequently 
subsist.  As  brought  to  the  attention  of  the  profession  by  Chapin, 
biology  furnishes  us  with  incontrovertible  evidence  of  these  facts.  In 
certain  mammalians,  such  as  the  kangaroo  and  the  American  opossum, 
the  mouth  of  the  fetus  is  directly  adherent  to  the  teat.  In  an  especially 
constructed  pouch  the  nourishment  and  growth  are  effected  in  this 
manner  vdthout  any  placental  connection  whatever.  In  these  mammals 
there  is  both  anatomical  connection  and  physiological  dependence  on 
the  mother.  In  placenta-forming  mammals  the  anatomical  connection  of 
the  young  is  severed  at  birth,  but  the  physiological  dependence  upon  the 
mother  remains  and  continues  until  further  development  of  the  organs 
of  locomotion  and  digestion  fit  it  for  independent  existence.  The 
attainment  of  this  independence  is  deferred  much  later  in  the  human 
species  than  in  any  other;  and  since  in  man  the  digestive  and  nervous 
systems  are  notably  undeveloped  at  birth,  it  is  to  be  expected  that  the 
secretion  of  the  mother's  breast  is  presumably  adapted  for  these  special 
needs. 

The  milks  of  all  species  of  mammals  have  certain  characteristics  in 
common,  in  that  they  all  contain  fat,  sugar,  proteids,  mineral  salts,  and 
water.  While  fat  is  necessary  for  the  proper  formation  of  the  osseous 
and  nervous  systems,  and  sugar  is  capable  of  being  transformed  and 
stored  up  in  the  body  as  fat,  both  of  these  have  more  ordinary  uses. 
It  may  be  said  in  general  that  fat  and  sugar  are  the  heat  and  energy 

(89)   ■ 


90  I \ FA  XT   FEEDIXG 

producing  elements  which  keep  the  young  ahve  and  furnish  the  motive 
power  to  the  body,  while  proteids,  which  alone  contain  nitrogen,  are 
the  real  constructive  elements  which  build  the  body,  making  blood, 
repairing  waste,  and  forming  new  cells  in  growth.  Fat  and  sugar  are, 
for  practical  purposes,  nuich  the  same  in  the  milks  of  all  species,  but 
this  is  not  the  case  with  the  proteids.  The  young  of  the  different  species 
cliifer  greatly  in  the  rapidity  of  their  growth  and  the  length  of  time  after 
birth  in  which  they  mature  and  become  independent  of  the  mothers' 
manunary  glands  for  nutrition.  This  readily  ex])lains  the  necessity  for 
decitled  differences  in  the  amount  of  the  tissue-building  proteids  in  the 
milks  of  the  different  species. 

MILK  PROTEIDS. 

The  proteids  of  milk  are  divisible  into  casein  and  a  group  of  soluble 
albuminous  bodies  formerly  classed  as  albumins.  Casein  is  precipitated 
in  more  or  less  solid  form  by  the  action  of  acids  alone  or  in  the  stomach 
during  the  process  of  digestion.  The  soluble  albuminous  bodies  are  not 
precipitated  by  acids  or  during  digestion,  but  remain  in  the  fluid  which 
separates  from  the  casein  and  are  readily  absorbed  by  the  digestive 
tract.  Moreover,  the  physical  characteristics  of  the  casein  curd,  formed 
in  digestion,  whether  small  or  large,  soft  or  tough,  bear  a  definite 
relation  to  the  type  of  food  consumed  by  the  adult  of  the  species  and  its 
digestive  organs.  This  latter  principle,  that  the  stomachs  and  digestive 
tracts  of  different  mammals  vary  in  construction  and  in  their  proportions 
according  to  the  kind  of  food  upon  which  the  adult  individuals  must 
live,  is  well  established  by  comparative  anatomy.  The  carnivorous 
animals  feed  upon  concentrated  food,  and  have  small  digestive  tracts. 
The  herbivorous  animals,  on  the  contrary,  consume  bulky  food  in  which 
the  proj)ortion  of  nutritious  matter  is  comparatively  small.  They  have 
roomv  digestive  organs,  which  functionate  best  when  distended. 

Taking  the  most  im]>ortant  examples  for  our  purposes  to  show  the 
adaptation  of  the  mother's  milk  to  her  young:  cows'  milk  coagulates 
in  large  masses  in  the  calf's  stomach,  filling  the  organ  and  thus  develop- 
ing the  digestive  capacity  against  the  time  when  it  shall  be  required. 
The  human  infant  has  a  very  different  type  of  stomach.  It  requires 
preparation  for  a  less  bulky  food,  and  its  smaller  stomach  receives  milk 
which  is  coagulated  in  small,  soft  flocculi.  But  this  difference  in  the 
way  the  casein  coagulates  in  the  milks  of  the  species  is  not  solely  one  of 
the  quantity  of  casein  contained  in  each  milk,  although  the  amount  is 
considerably  greater  in  cows'  milk  than  in  breast  milk,  else  when  cows' 
milk  is  proportionately  diluted  or  modified  to  resemble  breast  milk  the 
physical  characteristics  of  the  curds  should  be  the  same. 

This  is,  however,  not  the  case,  for  the  curds  found  in  such  modified 
or  diluted  cows'  milk  are  larger  and  tougher,  and  the  conclusion  is 
forced  upon  us,  although  not  as  yet  absolutely  proven,  that  there  are 
distinct  differences  in  the  caseins  of  the  various  mammalian  milks. 

Thes?  caseins  seem  to  be  dissimilar  bodies  which  react  to  rennet, 


MATERNAL   FEEDING  91 

acids,  or  the  digestive  juices  in  very  different  v^-ays,  and  it  is  definitely 
accepted  that  they  are  not  interchangeable  with  ec^iial  digestibility  for 
the  stomachs  of  the  young  of  different  species. 

Important  as  the  question  is,  our  knowledge  of  the  chemical  changes 
taking  place  in  casein  when  subjected  to  the  action  of  acids,  as  during 
digestion,  has  been  based  upon  a  false  theory,  owing  to  the  general 
acceptance  of  the  incorrect  deductions  draAvn  by  Hammarsten  from  his 
experiments.  He  wrongly  concluded  that  there  was  no  ground  for 
believing  that  any  chemical  combination  takes  place  between  the  casein 
and  the  acid  used  to  precipitate  it. 

The  recent  epoch-making  discoveries  of  Van  Slyke  and  Hart^  com- 
pletely disprove  this,  and  show  clearly  that  the  acid  combines  directly 
with  the  casein,  forming  a  definite  chemical  compound. 

The  possession  of  such  a  clear  conception  of  the  processes  taking 
place  during  the  earlier  stages  of  the  digestion  of  milk  has  long  been 
awaited,  and  will  prove  invaluable  in  comprehending  the  hitherto 
obscure  and  complex  problems  of  infant  feeding. 

^Mien  the  young  animal  is  born  the  mammary  glands  secrete  colos- 
triun,  which  is  gradually  transformed  into  true  milk.  Just  as  in  the 
lower  orders  of  animal  life  the  stomach  is  a  later  and  specialized  develop- 
ment of  a  part  of  the  intestinal  tube,  the  digestion  of  the  newborn  is 
intestinal  until  the  functions  of  the  stomach  are  developed.  Colostrum  is 
less  readily  coagulated  than  milk,  and,  being  suited  for  intestinal  digestion, 
passes  quickly  through  the  stomach,  but  in  its  passage  has  the  effect 
of  awakening  and  stimulating  the  digestive  secretions  of  the  stomach. 

Digestion  of  Casein. — Casein  occurs  in  milk  combined  with  calcium, 
and  is  now  known  as  calcium  casein.  The  earliest  secretion  of  the 
young  stomach  is  the  enzyme  rennet.  This  ferment,  acting  upon  the 
calcium  casein  of  milk,  forms  a  soft  clot  known  as  calcium  paracasein 
(junket).  Until  acid  is  secreted  this  calcium  paracasein  clot  may  pass 
on  into  the  intestine,  where  it  is  readily  digested  by  the  pancreatic  and 
intestinal  secretions.  In  the  absence  of  acid,  pepsin  cannot  attack  cal- 
cium paracasein.  But  when  the  stomach  begins  to  secrete  hydrochloric 
acid  in  small  quantities  the  acid  combines  with  the  calcium  of  the 
calcium  paracasein  clot,  releasing  free  paracasein  (a  base-free  proteid) 
which  forms  a  firmer  curd.  This  curd  of  free  paracasein  is  now  readily 
attacked  by  pepsin,  and  true  stomach  digestion  is  inaugurated. 

I'his  free  paracasein  presents  new  physical  characteristics,  forming  a 
curd  firmer  than  the  soft  calcium  paracasein  clot,  and  having  a  ten- 
dency to  shrink.  It  is  soluble  in  a  dilute  solution  of  common  salt,  is 
readily  digested  by  pepsin,  and  is  probably  almost  exclusively  formed 
during  the  period  when  the  young  stomach  secretes  but  a  small  amount 
of  weak  hydrochloric  acid,  only  sufficient  to  combine  with  and  remove 
the  calcium  from  those  parts  of  the  paracasein  clot  with  which  it  comes 
in  contact.  The  remaining  unaltered  paracasein  still  passes  on  into  the 
intestine  to  undergo  digestion.     iVs  the   acid   secreted  by  the  stomach 

1  Bulletin  261,  the  New  York  Agricultural  Station,  Geneva,  N.  Y.,  January,  1905. 


92  IXFAXr   FEEDIXG 

increases  to  a  point  slifjjhtly  beyond  that  necessary  to  combine  with  the 
calcium  of  the  portions  of  the  paracasein  witli  whicii  it  can  come  in  con- 
tact, the  excess  of  acid  is  used  up  in  combining  (Hrectly  witli  the  most 
exposed  ])arts  of  the  free  paracasein,  formiiifi;  hych'ochloridc  of  para- 
casein a  definite  compound  of  proteid  witli  acid.  This  is  tout^her  than 
the  free  paracasein,  tliffers  from  the  latter  in  not  being  soluble  in  dilute 
salt  solution,  has  a  similar  or  greater  tendcMicy  to  shrink,  and,  as  long  as 
the  hydrochloric  acid  secreted  is  completely  used  up  in  forming  the 
products  mentioned,  is  not  so  easily  or  ra])idly  digested  by  pepsin  as 
the  free  paracasein.  It  therefore  tends  to  stay  longer  in  the  stomach 
and  to  prolong  gastric  digestion. 

But  since  the  paracasein  clot  is  attacked  upon  its  surface  by  acid, 
and  curds,  especially  of  the  milks  of  diifercnt  species,  may  vary  much 
in  siz(>  and  density,  the  chemical  action  of  the  acid  may  ])cnetrat(^  them 
to  ditferent  degrees,  and  it  is  consequently  entirely  possible  to  have  at 
the  same  time,  within  the  curd  or  in  the  gastric  contents  in  varying 
proportions,  paracasein  hydrochloride,  free  paracasein,  and  calcium 
paracasein  depending  either  upon  the  admixture  or  contact  of  the  acid 
with  the  stomach's  contents  or  upon  the  strength  and  (piantity  of  its 
gastric  secretions. 

As  the  stomach  becomes  able  to  secrete  more  acid,  more  of  the  para- 
casein is  changed  into  free  paracasein  and  the  acid  salt  of  paracasein; 
more  of  the  milk  then  remains  in  the  stomach  prepared  for  gastric 
digestion,  and  this  stimulates  more  secretion  of  hydrochloric  aciil  and 
pepsin.  When,  finally,  during  the  process  of  digestion  more  acid  is 
secreted  than  can  combine  with  and  saturate  the  exposed  portions  of 
the  paracasein  so  that  free  acid  is  present,  pepsin  digests  the  hydro- 
chloride of  paracasein  with  greater  facility.  Although  digestion  pro- 
gresses more  rapidly  when  free  acid  is  present,  this  is  now  counter- 
balanced by  the  large  f[uantity  of  material  requiring  stomachic  digestion. 

We  are,  therefore,  in  a  position  to  grasp  one  of  the  most  remarkable 
phenomena  in  nature,  namely,  that  milk  which  itself  retains,  after  the 
end  of  the  colostrum  period,  practically  the  same  composition  through- 
out lactation,  is  changed  by  the  action  upon  it  of  the  developing  and 
increasing  gastric  secretions  of  the  young  into  forms  and  compounds 
which  at  first  recjuire  moderate,  and  later,  more  extended  gastric  diges- 
tion, by  which  means  the  stomach  is  ])rogressively  called  upon  to  ])erform 
more  and  more  work,  until  it  is  sufficiently  developed  anatomically  and 
physiologically  for  the  animal  to  begin  its  subsistence  upon  the  types 
of  food  consumefl  by  the  adult  of  its  species. 

Although  this  automatic  adjustment  of  the  milk  of  the  mother  to  the 
digestive  secretions  of  her  young  is  under  normal  conditions  practically 
perfect,  there  are  marked  differences  in  the  form  and  density  of  the 
curds  formed  from  the  caseins  of  different  milks,  so  that  the  use  of 
the  milk  of  another  species  may  readily  cause  difficulty  or  disturbance. 
The  time  then  has  passed  for  considering  milks  of  dilTerent  species  to 
be  practically  the  same  because  of  gross  resemblances.  Human  milk 
is  especially  designed   for  the   human   infant  and   cannot   be  exactly 


MATERNAL   FEEDING  93 

imitated  from  the  milk  of  the  cow  or  any  other  animal,  much  less  in  the 
laboratory  of  the  manufacturer  of  infant  foods. 

Nature  intended  that  the  human  infant  should  be  nursed  at  the 
maternal  breast  after  birth  just  as  much  as  that  it  should  be  nourished 
by  the  placental  blood  before  birth.  The  secretion  of  the  breast  is 
designed  not  alone  to  support  life,  nor  only  to  furnish  material  for 
ordinary  growth,  but  physiologically  to  complete  the  development  of 
those  organs  which  are  but  partially  developed  at  birth. 


THE  SECRETION  OF  THE  HUMAN  BREASTS. 

Colostrum. — The  early  secretion  of  the  breasts  after  the  birth  of  the 
child  is  distinctly  different  from  that  which  is  later  established.  It  is 
less  sweet,  of  a  yellow  color,  scanty  in  amount,  less  readily  coagulated, 
acting  as  a  stimulant  to  the  digestive  organs  and  containing  micro- 
scopically, besides  fat  globules  of  unequal  size,  certain  cells  called 
colostrum  corpuscles.  These  have  a  small,  degenerated  nucleus,  a  gran- 
ular protoplasm,  and  are  considerably  larger  than  the  fat  globules. 
Their  persistence  in  the  gradually  changing  secretion  marks  the  duration 
of  the  colostrum  period.  It  is  most  distinctive  during  the  first  two  to 
three  days  when  the  secretion  is  small,  the  color  deeper,  and  the  cor- 
puscles more  numerous.  The  proteid  percentage  is  increased  in  propor- 
tion to  the  presence  of  the  corpuscles,  which  normally  disappear  in  from 
seven  to  twelve  days  after  birth.  Persistence  beyond  this  period  or 
recurrence  of  the  corpuscles  later  in  the  milk  is  abnormal  and  liable 
to  cause  disturbance  of  the  infant's  digestion.  For  this  reason,  except 
for  newborn  babies,  a  wet-nurse  should  have  passed  the  colostrum 
period.  Where  there  is  persistent  digestive  disturbance  at  the  mother's 
breast  immediately  after  birth,  other  nourishment  may  be  given  and  the 
breast  pumped  until  after  this  period  is  passed,  when  nursing  may 
be  usually  resumed. 

Breast  Milk. — Breast  milk  is  an  opaque,  bluish-white,  rather  sweet 
fluid.  Its  reaction  is  usually  stated  to  be  amphoteric,  but  with  phenol- 
phthalein,  a  much  more  sensitive  indicator  than  litmus,  it  has  been 
shown  by  Kerley,  Gieschen,  and  Myers  to  be  faintly  acid.  The  average 
specific  gravity  is  1031,  with  variation  from  1028  to  1034.  The  addition 
of  weak  acid  causes  a  moderate  coagulation  in  fine,  soft  flocculi.  The 
fat  globules  under  the  microscope  are  approximately  of  the  same  size. 

After  the  colostrum  period,  with  its  low  sugar  and  higher  proteids  and 
salts,  is  passed  the  composition  of  breast  milk,  when  uninfluenced  by 
ill  health  or  faulty  hygiene,  becomes  fairly  uniform.  Adriance,  however, 
has  shown  that  while  the  sugar  tends  to  rise  very  slightly,  the  proteids 
and  salts  toward  the  end  of  lactation  show  a  moderate  descending  curve, 
which  is  doubtless  one  of  the  factors  in  the  causation  of  those  cases  of 
rachitis  which  result  from  unduly  prolonged  nursing.  The  composition 
of  milk  will  be  more  fully  discussed  in  the  chapter  on  "Cows'  Milk." 

Experience  teaches  that  the  maintenance  of  certain  normal  relations 


94  INFAXT   FEEDING 

between  the  percentages  of  fat  and  jjroteids  are  of  importance  for  normal 
digestion  and  proper  nntrition. 

Diarrhea  and  poor  (hgestion  occnr  with  excessive  fat,  incHgestion 
with  too  high  proteids,  and  poor  nntrition  with  deficient  proteids  or  fat. 
Decrease  in  tiie  hitter  canses  a  tendency  to  constipation. 

Nitrogen  being  necessary  for  tissue  buihhng,  the  ])r()teids  which 
contain  the  nitrogen  of  the  milk  become  ])erhaps  the  most  in'.portant 
element.  The  s()lnl)le  proteids  which  remain  in  solution  are  usually 
stated  to  exceed  in  amount  the  casein  which  is  preci-pitated  during 
digestion,  and  this  constitutes  but  one  of  the  important  differences 
between  woman's  and  cows'  milk.  In  the  latter  the  greater  actual 
as  well  as  proportionate  amount  of  casein,  which  is  also  of  a  diH'ercnt 
character  from  that  of  breast  milk  and  coagidates  in  larger  and  firmer 
masses,  renders  it  more  difficult  of  digestion.  But  the  mere  enumera- 
tion of  these  elements,  fat,  lactose  (milk-sugar),  soluble  proteids,  casein, 
and  salts,  whose  amounts  can  be  estimated,  does  not  ])robably  reveal 
some  of  the  most  vital  elements,  namely — the  ferments  and  protective 
principles  which  adapt  breast  nn'lk  to  the  infant's  (Hgcstion,  and  which, 
as  shown  by  Roger  and  others,  render  the  nursing  infant  largely  inmiune 
to  the  infections  diseases. 

Automatic  Adjustment  of  Breast  Milk  to  the  Stomach  Secretions. — The 
stomach  of  the  infant  at  birth  is  ])ut  sliglitly  developed  both  in  size  and 
power  of  secretion.  The  first  secretion  of  the  breasts,  colostrum,  is 
rich  in  soluble  proteids,  w'hich  require  little  if  any  action  by  the  stomach 
before  they  can  be  absorbed  by  the  intestines,  into  wliich  they  are  (|uickly 
passed;  but  they  also  have  the  property  of  stimulating  the  hitherto 
unused  functions  of  secretion  and  absorption,  so  that  during  the  gradual 
change  to  the  more  permanent  breast  milk  the  stomach  is  gently 
initiated  into  its  new  duties. 

The  rennet  f(>rment  secreted  by  the  stomach  acts  uj)on  the  casein, 
forming  a  flocculent  precipitate  which  tends  to  remain  longer  in  the 
stomach.  Hydrochloric  acid  is  soon  secreted,  which  acts  upon  this, 
forming  a  soft,  finely  divided  curd,  and  pepsin  is  secreted  to  digest 
it.  The  stomach  thus  takes  upon  itself  more  and  more  of  the  work  of 
digestion,  increasing  the  com])lexity  of  the  products  formed,  the  firmness 
of  the  nuisses,  and  the  time  re<|uired  for  the  completion  of  stomach 
digestion.  This  furnishes  a  rational  explanation  for  the  need  of  length- 
ening the  interval  between  nursings,  and,  when  cows'  milk  is  the  food, 
of  allowing  sufficient  time  for  the  last  meal  to  leave  the  stomach,  since 
cows'  milk  forms  firmer  masses  and  recjuires  longer  digestion.  Thus 
we  see  that  while  breast  milk  after  the  end  of  the  colostrum  jicriod  does 
not  materially  change  during  lactation,  the  stomach  elaborates  from 
this  unchanging  supply  of  raw  material  new  compounds  which  make  new 
demands  upon  the  development  of  that  organ,  until  it  is  at  last  fitted 
to  begin  the  digestion  of  other  forms  of  food  at  the  time  of  weaning. 

The  Chemical  Composition  of  Breast  Milk. — This  has  no  hard-and-fast 
lines  in  percentages.  Averages  obtained  by  combining  the  results  of 
many  examinations  are  useful  in  a  schematic  way,  but  in  nowise  inform 


MATERNAL  FEEDING  95 

us  of  the  variations  which  take  place  in  the  milk  of  different  women, 
and  even  in  the  milk  of  the  same  woman  on  different  days  and  under 
different  circumstances;  these  are  influenced  by  the  length  of  interval 
between  nursings,  by  her  health,  diet,  and  the  condition  of  her  nervous 
system.     Holt  gives  the  following  table: 

Composition  of  Breast  Milk  (Holt). 

Average  Common  healthy 

per  cent.  variations  per  cent. 

Fat 4.00  3.00     to     5.00 

Sugar 7.00  6.00      "      7.00 

Proteids 1.50  1.00      "      2.25 

Salts 0.20  0.18      "      0.25 

Water 87.30  89.82      "    85.50 

100.00  100.00  100.00 

It  should  be  borne  in  mind,  however,  that  considerable  variations  from 
this  average  exist  in  the  milk  of  many  mothers  whose  children  are 
digesting  perfectly.  In  a  series  of  analyses  from  14  healthy  breasts, 
upon  which  infants  were  thriving,  Harrington  found  the  proteids  to 
vary  from  1.08  to  4.17  per  cent.  Only  4  were  below  2  per  cent.,  5 
exceeded  3.50  per  cent.,  and  of  these  2  were  somewhat  over  4  per  cent. 
The  fat  varied  from  2  to  5  per  cent.  From  this  we  must  conclude  that 
the  usual  averages  laid  down  for  the  fat  and  proteid  of  breast  milk  are 
no  criterion  of  the  digestive  powers  of  the  individual  infant.  They  have 
much  the  same  variability  that  we  find  in  infants  for  the  digestion  of 
the  fat  and  proteids  of  cows'  milk,  although  the  latter  are  more  difficult 
of  digestion,  which  to  some  extent  explains  the  failure  of  attempts  to 
feed  all  children  artificially  upon  modifications  of  cows'  milk  based 
rigidly  on  these  averages.  On  the  other  hand,  when  a  chemical  analysis 
shows  a  decided  variation  from  these  accepted  averages,  with  disturbed 
digestion  in  the  infant,  especially  if  thei'e  be  high  proteids,  we  are  in 
possession  of  valuable  data  upon  which  to  base  our  tentative  treatment 
of  the  mother  to  remove  these  probable  causes  of  the  disturbance. 

The  Clinical  Examination  of  Breast  Milk. — When  proximity  to  a  well- 
equipped  laboratory  and  the  circumstances  of  the  patient  allow,  the 
complete  chemical  analysis  of  the  milk  gives  us  the  most  accurate  and 
valuable  information,  but  the  inability  to  secure  such  analysis  should 
not  lead  the  practitioner  to  neglect  the  simpler  methods  of  gaining  an 
approximate  knowledge  of  the  quality  of  a  given  milk,  which  he  may 
himself  carry  out  with  very  little  time  or  expenditure.  IMost  important 
for  our  purpose  is  a  knoAvledge  of  the  specific  gravity  and  of  the  percent- 
ages of  fat  and  proteids  in  any  case  where  the  quality  of  the  milk  is 
questioned,  to  which  may  be  added,  if  desired,  a  microscopic  exami- 
nation. The  milk-sugar,  as  we  have  seen,  varies  very  little  and  may  be 
disregarded.  The  salts  or  mineral  matter,  although  they  vary,  we  have 
as  yet  no  known  method  of  influencing,  and  are  of  minor  importance. 
Since  in  many  cases  calling  for  examination  only  small  quantities  can 
be  obtained  with  the  breast  pump,  our  apparatus  must  be  small  enough  to 
utilize  this.      Milk  for  any  test  should  be  taken  from  about  the  middle  of 


96 


IXF.WT   FEEDIXG 


tilt'  niirsino;,  wluMi  the  hirast  is  about  half-full,  to  obtain  average  milk  and 
to  avoid  the  thinner  first  milk  and  richer  last  milk.  About  one-half  ounce 
is  retjuired.  The  speciHc  gravity  may  be  taken  with  any  small  urinometer. 
Determination  of  Fat. — For  the  estimation  of  the  fat  small  tubes  are 
now  made  and  sold  which  can  be  used  in  the  centrifuge  apparatus  now 
employed  by  most  physicians,  and  which  are  upon  the  same  principle 
as  the  larger  tubes  of  the  Babcock  machine  used  for  that  ])urpose  in 
the  modern  dairy,  'iliis  latter  can  l>e  used,  but  requires  at  least  17.50  c.c. 
(5ss)  to  determine  the  fat.  A  simpler,  less  accurate,  but  still  valuable 
a|)paratus  made  by  Eimer  &  Amend,  of  New  York,  and  costing  S2,  is  the 
Ilolt  A[)paratus  for  the  Clinical  Examination  of  Breast  Milk  (Fig.  25), 


liolt's  apparatus. 


which  consists  of  a  small  lactometer  (hydrometer)  and  two  tubes  con- 
taining 10  c.c.  each,  graduated  in  hundredths,  one  of  which  is  filled  with 
milk  exactly  to  the  100  mark  and  allowed  to  stand  twenty-four  hours, 
after  which  the  amount  of  cream  which  has  risen  may  be  read  upon  the 
.scale.  Five  per  cent,  of  cream  is  equal  to  3  per  cent,  of  fat  in  the  milk. 
For  emergency  purposes  this  may  be  roughly  imitated  by  using  a  nar- 
row, flat-bottomed  te.st-tube  and  a  centimetre  scale. 

Determination  of  Proteids. — Unfortunately  the  exact  percentage  of 
proteids  can  only  be  determined  by  elaborate  chemical  analysis,  but  an 
approximate  estimate  can  be  made  from  the  specific  gravity  and  the 
cream  percentage.  This  depends  upon  the  principle  that  fat  being 
lighter  than  water  and  proteids  heavier,  a  high  cream  content  lowers 
the  specific  gravity  and  a  low  cream  content  raises  the  specific  gravity. 


MATERNAL   FEEDING  97 

Therefore,  a  high  specific  gravity  with  high  cream  indicates  excessive 
proteids,  and  a  low  specific  gravity  with  low  cream  deficient  proteids. 
Deductions  from  the  findings  in  any  given  case  may  best  be  made  accord- 
ing to  the  foUov^ing  table,  which  accompanies  the  Holt  apparatus: 

Woji.^-x's  Milk. 
Specific  gravity,  70"  F.  Cream  in  24  hours.  Proteids  (calculated). 

Average      .       .       .  1-031  7  per  cent.  1.5  per  cent. 

Normal  variations     .  1.028-1.029  8  per  cent,  to  12  per  cent.  Normal  (rich  milk) . 

Normal  variations     .  1.032  5  per  cent,  to  6  per  cent.  Normal  (fair  milk). 

Abnormal  variations     Low  (below  1.028).      High  (above  10  per  cent.).  Normal  or  slightly  below. 

Abnormal  variations     Low  (below  1.02S).      Low  (below  5  per  cent.).  Very  low  (very  poor  milk). 

Abnormal  variations     High  (above  1.032).  High.  Very  high  (very  rich  milk). 

Abnormal  variations      High  (above  1.032).  Low.  Normal  (or  nearly  so). 

Microscopic  Examination. — This  is  of  no  value  in  determining  the  rich- 
ness of  fat,  but  may  be  employed  to  search  for  colostrum  corpuscles,  pus, 
red  blood  cells,  or  by  staining  to  show  the  presence  of  micro-organisms. 


MANAGEMENT  OF  LACTATION. 

It  is  quite  as  often  with  ignorance  of  the  proper  rules  to  be  followed 
during  lactation  as  wdth  the  correction  of  abnormalities  in  breast  milk 
that  the  practitioner  is  called  upon  to  deal,  and  the  management  of 
the  nursing  mother  and  her  child  must  be  considered  largely  from  this 
standpoint. 

The  correct  management  of  lactation  begins  at  birth  with  respect 
both  to  diet  of  the  mother  and  the  nursing  of  the  infant.  The  infant 
.should  be  placed  at  the  breast  as  soon  as  the  mother  is  somewhat  rested, 
and  for  the  following  twenty-four  hours  it  should  be  allowed  to  nurse 
every  six  hours.  The  second  day  an  interval  of  four  hours  is  observed, 
and  with  the  establishment  of  the  flow  on  the  third  day  the  infant  should 
nurse  every  two  hours.     I'he  following  table  gives  this  succinctly : 

Nursing  Schedule. 

Interval 
Age.  through  day 

(hours). 

During  first  day 6 

"      second  day 4 

"      third  to  twenty-eighth  day,  inclusive      .    2 
"      second  to  third  months,  inclusive     .       .    2% 
"      fourth  to  fifth  months  "  .        .    3 

"      fifth  to  eleventh  months      "  .       .    3 

Frequent  and  prolonged  tugging  at  the  breast,  when  the  secretion  is 
scanty  during  the  first  two  or  three  days,  only  serves  to  increase  the 
danger  of  producing  excoriations  of  the  nipples.  In  the  interval  the 
infant  should  be  given  three  or  four  teaspoonfuls  of  plain  boiled  water 
every  two  hours,  which  stimulates  the  circulation  of  the  stomach  mucosa, 
increases  the  urinary  flow,  washing  out  from  the  urinary  tubules  the 
urates  whose  presence  in  concentrated  urine  leads  to  much  unexplained 
discomfort  and  crying  of  the  nev/born.  Infants  given  water  during  this 
7 


Number  of 

nursings  in 

24  hours. 

Night  nursings 

between  9-10 

P.M.  and  6-7  a.m. 

4 

1 

6 

2 

10 

2 

8 

1 

7 

1 

6 

0 

9S  IXFAXr  FEEDING 

period  show  less  initial  loss  of  weight.  Night  nursings  should  be  strictly 
limited  aeeordiiig  to  the  seliedule,  in  tlie  interest  of  both  mother  and 
child.  After  nursing  the  baby  siiould  be  laid  down  to  inaugurate  good 
habits  at  the  .start.  If  the  baby  is  feeble  or  puny  at  birth,  a  5  per  cent, 
.solution  of  milk-sugar  may  be  substituted  for  plain  water.  If  the  flow 
of  milk  does  not  begin  on  the  third  day,  especially  if  the  infant  shows 
the  so-called  inanition  tenii)erature,  which  may  reach  108°  F.  or  over  and 
is  due  to  lack  of  food,  a  low  formula — fat  l.OO,  .sugar  5.00,  proteidsO.33 
(.see  page  14()) — should  be  given,  replacing  each  alternate  two-hourly 
nursing,  and  will  be  followed  by  a  drop  in  the  temperature. 


DIET  OF  THE  NURSING  MOTHER. 

The  diet  of  the  nursing  mother  should  at  all  times  include  abundant 
fluids  in  order  that  tiie  .secretion  of  the  breasts  may  be  carried  on 
witlioiit  encroaching  uj)on  other  fluids  recpiired  for  normal  functions. 
Tile  amount  demanded  is  nmch  larger  than  that  furnished  i)y  ordinary 
diet  and  should  not  be  left  to  the  inclination  of  the  patient,  but  extra 
fluids  should  be  given  at  stated  intervals.  This  should  be  definitely 
impressed  upon  the  patient,  nurse,  or  attendant  friends.  ''J'he  adminis- 
trati(»n  of  fluids  should  be  begun  as  soon  after  childbirth  as  the  stomach 
will  retain  thiMU.  Tli(y  adtl  to  the  mother's  comfort  and  flush  the  body 
through  the  kidneys  of  much  effete  matter  which  may  otherwise  be 
excreted  in  part  by  the  breasts,  disturbing  the  child.  The  urine  of  the 
mother  during  the  first  few  days  of  the  parturient  |)eriod  is  usually  dark 
and  concentratcMl,  owing  to  the  decreased  intake  of  fiuids  during  parturi- 
tion, lo.ss  of  blood,  and  the  rapid  tissue  changes  in  the  period  of  readjust- 
ment. On  the  first  day  give  at  frequent  intervals  water  and  nutritious 
fiuids,  such  as  milk  and  gruels,  or,  if  necessary,  mutton-broth  or  chicken- 
broth.  On  the  second  day,  nutritious  fiuids  and  simple  semisolid  food. 
On  the  third  day,  in  an  uncomplicated  case,  digestible  .solid  food  may 
be  added.  This  may  usually  include  a  small  amount  of  meat,  once  a 
day,  if  the  child  is  having  no  digestive  disturbance  due  to  too  high  fat 
or  proteids  which  the  ingestion  of  meat  by  the  mother  may  increase  or 
maintain.  In  general,  during  lactation,  the  mother  should  eat  abundantly 
of  tho.se  simple,  nutritious  articles  of  food  which  .she  knows  by  experience 
she  can  eat  and  digest  without  difficulty.  Fewer  special  articles  are 
to-day  tabooed  than  formerly.  Milk,  eggs,  meat,  cereals,  fruits,  and 
vegetables  allow  a  sufficient  range.  Certain  of  the  stronger  vegetables 
must  be  avoided  by  .some  mothers,  while  others  takethem  with  impunity. 
Tea  and  cottVe  should  be  partaken  of  sparingly  if  at  all.  They  are 
stimulants  which  have  no  milk-making  properties,  and  the  former  espe- 
cially may  di.sturb  the  mother's  digestion  and  its  alkaloids  affect  the 
child  through  the  milk.  Beer  has  little  nutritive  value,  and  this  and 
other  alcoholics  (jften  disturb  the  infant.  Malt  extracts  have  more  value 
and  are  chiefly  useful  to  increa.se  the  fat  in  the  milk,  although  at  times 
they  also  increase  the  flow.    Besides  plain  water  I  recommend ; 


MATERNAL  FEEDING  99 

1.  Milk. — Of  this  at  least  one  quart  should  be  drunk  daily.  No 
argument  seems  necessary  to  show  that  this  furnishes  in  the  simplest 
and  most  readily  assimilable  form  the  materials  needed  for  milk  secre- 
tion. In  cases  of  faulty  digestion  it  may  be  diluted,  heated,  peptonized, 
or  given  as  zoolak,  or  kumyss. 

2.  Cornmeal-gruel. — While  not  necessarily  required  by  those 
mothers  who  naturally  have  an  abundant  flow  of  milk,  experience  has 
shown  that  this  has  no  equal  in  restoring  a 

deficient  secretion.     It  should  be  cooked  at  fig.  26 

least  four  hours  in  a  double  boiler  (Fig.  26) 

and  well    salted   to   taste.      When  used,  it 

should  be  thinned  with  water  or  milk  so  that 

it  can  be  drunk,  not   eaten  with   a   spoon. 

Two  or  three  bowlfuls  should  be  taken  in  the 

twenty-four  hours.    If  there  be  any  difficulty 

in  digesting  it,  it  may  be  dextrinized,  which 

both    thins    it    and    allows    the    use    of    more  Double  farina  boiler. 

cornmeal  in  each  portion,  or,  if  need  be,  fur- 
nishes more  nutritious  material  with  smaller  bulk.     Such  dextrinized 
gruel  is  made  as  follows: 

Take  three-fourths  teacupful  yellow  cornmeal,  one  quart  cold  water, 
two  teaspoonfuls  cereo,  and  sufficient  salt  to  flavor.  Mix  in  a  double 
boiler;  bring  slowly  to  a  boil  to  allow  the  dextrinizing  agent  to  act,  and 
cook  for  two  or  three  hours.  It  may  be  strained  and  taken  plain  or 
mixed  with  equal  parts  of  milk  if  preferred. 

3.  Cocoa. — Some  mothers  can  digest  as  a  hot  beverage,  in  place  of 
tea  or  coffee,  the  so-called  "cocoas,"  which  are  apparently  only  chocolates 
from  which  a  part  of  the  oil  has  been  removed.  Better  usually  than 
these,  and  without  effect  upon  the  digestion,  is  the  cracked  cocoa  bean, 
which,  after  prolonged  boiling,  loses  its  first  slightly  bitter  taste  and 
makes  an  agreeable,  nutritious  beverage.  The  pot  in  which  it  is  cooked 
should  be  kept  simmering  on  the  back  of  the  range,  and  water  added 
from  time  to  time.  It  should  be  emptied  but  once  a  week,  and  a  small 
quantity  of  the  cracked  bean  added  daily. 


HYGIENE  OF  THE  NURSING  MOTHER. 

Postpuerperal  Anemia. — Most  women  are  anemic  after  childbirth 
and  this  condition  is  usually  neglected.  Proper  digestion  and  secretion 
is  dependent  upon  the  quality  of  the  blood.  Blaud's  pills  are  a  satis- 
factory form  of  iron. 

Constipation. — Constipation  is  not  compatible  with  good  health,  and 
unless  relieved  effete  material  may  be  thrown  off  in  the  milk.  Cascara 
in  some  form  is  best  adapted  for  routine  use.  Salines  are  contra- 
indicated  in  nursing  mothers,  as  they  reduce  the  flow  of  milk. 

Exercise. — Daily  exercise,  either  by  driving  or,  far  preferably,  by 
walking  should   be  begun  at  the  earliest  moment  that  the  mother's 


100  IM'AXr  FEEDIXG 

condition  ullows.     These  walks  should  extend,  if  possible,  to  one  to  two 
miles  diiily,  hut  should  uhvays  stop  short  of  actual  fatigue. 

1  have  long  taken  the  position  that  in  the  vast  majority  of  cases  the 
milk  of  a  healthy  mother  who  takes  sufficient  out-of-door  exercise  and 
eats  sensible,  plain  food,  supplemented  by  abundant,  nutritious  fluids, 
will  but  seldom  fail  to  agree  with  her  infant;  or,  conversely,  if  the  breast 
milk  is  scanty  or  appears  to  disagree  with  her  infant,  either  the  mother 
is  out  of  health,  anemic,  or  constipated,  she  is  securing  too  little  fresh  air 
and  exercise,  she  is  taking  too  little  fluid  food  of  the  right  kind,  or  she 
is  not  upon  a  j)lain,  sensible  diet.  Surely  the  busiest  practitioner  has  the 
time  toencjuire  into  these  details  and  to  remedy  the  errors,  even  if  he 
has  no  time  or  facilities  for  analyses  of  the  breast  milk.  Were  this  always 
done,  and  especially  if  proper  instructions  were  given  to  each  mother 
during  her  convalescence,  far  fewer  children  Avould  be  needlessly 
deprived  of  the  nourishment  intended  for  them  by  nature. 


DISTURBANCES  OF  THE  INFANT  DURING  LACTATION. 

The  principle  has  been  laid  down  above  that  the  hygiene  or  the  diet 
of  the  mother  is  usually  at  fault  where  a  healthy  mother  does  not  satis- 
factorily nurse  her  infant,  and  that  the  first  duty  of  the  physician  in  such 
a  case  is  to  correct  these  errors,  which  will  often  alone  serve  to  remove 
the  difficulty.  At  the  same  time  careful  in(|uiry  should  be  made  into 
the  nursing  habits, and  too  fre(|uent  or  irregular  nursings,  which  directly 
influence  the  quality  of  the  milk,  should  be  corrected.  Also  an  analysis 
of  the  milk  should  be  obtained  where  it  is  possible,  and  if  either  fat  or 
proteids  vary  distinctly  from  the  general  averages  contained  in  the 
table,  special  measures  may  be  adopted  to  influence  them  if  relief  is 
not  obtained  from  the  changes  which  have  already  been  inaugurated. 
The  first  step  would  be  to  determine  whether  the  quantity  of  the  milk 
is  sufficient,  and  should  lead  to  an  inspection  of  the  breasts  to  determine 
whether  they  fill  properly  during  the  nursing  intervals.  Large,  fat 
breasts  do  not  always  secrete  well,  nor  small  breasts  necessarily  give 
an  inadequate  supply.  The  mother's  sensation  of  fulness  or  emptiness 
of  the  breasts  may  be  relied  upon  but  moderately.  The  facility  with 
which  the  milk  may  be  drawn  by  the  breast  pump  is  often  a  valuable 
clue,  but  the  plan  of  weighing  the  baby  upon  a  scale  which  registers 
ounces,  immediately  before  and  after  nursing  without  any  change  of  its 
garments,  and  repeating  this  a  few  times  at  different  hours  of  the  day, 
gives  the  most  accurate  data.  IVIuch  may  be  learned  also  from  the 
behavior  of  the  infant  at  the  breast  and  from  its  stools.  If  nursing  is 
prolonged  thirty  minutes  or  more  the  milk  is  probably  scanty;  or  if  the 
infant,  after  a  f(>w  minutes  at  the  breast,  drops  the  nipple  in  disgust 
and  cries,  the  breast  is  probably  empty. 

Restlessness,  distifrbed  or  short  sleep,  associated  with  frequent  stools 
which  consist  principally  of  dark-green  mucus  with  very  little  fecal 
matter,  in  small  flakes  the  size  of  flattened  oats,  indicate  an  inadequate 


MATERXAL    FEEDIXG  101 

supply.  The  quantity  of  residue  and  the  deep  green  color  of  the 
mucus  differentiate  this  condition  from  a  diarrhea,  especially  if  the 
flakes  have  the  normal  orany;e-vellow  color. 


ABNORMALITIES  OF  BREAST  MILK. 

The  ahnormaliiies  of  breast  milk  may  be:  (1)  Normal  flow  vdth  excess 
of  either  fat  or  proteids  or  of  both.  (2)  Normal  or  excessive  flow  w^ith 
deficiency  of  fat  or  proteids  or  of  both.  (3)  Scanty  flow  of  good  quality. 
(4j  Scanty  flow  of  poor  quality. 

The  usual  rules  given  to  meet  special  indications  are  as  follows: 

To  increase  quantity:  Give  mother  more  nutritious  fluids  in  her  diet, 
especially  cornmeal-gruel,  and  reassure  her,  if  anxious. 

To  increase  the  fat:  Give  more  meat  and  possibly  prescribe  malt 
extract  (not  beer). 

To  decrease  the  fat:    Reduce  the  meat  in  the  diet. 

To  increase  the  proteids:  Give  more  meats,  eggs,  and  cereals,  and 
lessen  the  exercise  taken. 

To  decrease  the  proteids:  Order  exercise  by  walking,  short  of  fatigue, 
that  the  proteids  may  be  used  up  and  not  secreted. 

In  almost  every  case  other  matters  of  health  and  hygiene  will  require 
attention,  such  as  anemia  or  constipation,  as  above  mentioned.  All 
sources  of  nervous  strain  should  be  removed  if  possible.  Anxiety  con- 
cerning the  ability  to  nurse  must  be  relieved  by  cheerful  reassurance. 
If  the  mother's  sleep  is  broken  the  infant  should  be  removed  at  night 
to  another  room,  out  of  her  hearing.  iNIany  mothers,  from  a  sentimental 
feeling  of  duty  or  from  lack  of  assistance,  rarely  get  out  into  the  open 
air.  This  reacts  upon  their  health.  In  the  interest  of  her  infant  the  mother 
should  daily  seek  out-door  exercise  and  fresh  air  as  a  matter  of  routine. 
Lactation  should  not  be  made  a  drudgery.  If  the  short  nursing  intervals 
leave  no  time  for  simple  recreation,  this  should  be  made  possible  by 
one  or  even  two  bottle  feedings  at  hours  which  will  give  the  mother  the 
greatest  freedom.  A  nursing  baby  thus  trained  to  take  one  bottle  a  day 
is  ensured  against  mishaps  in  case  of  illness  of  the  mother  or  departure 
of  the  wet-nurse,  and  the  knowledge  and  apparatus  are  at  hand  against 
such  an  emergency.  Wet-nurses  especially  are  more  tractable  when  they 
know  that  the  infants  can  take  other  food  and  are  not  absolutely 
dependent  upon  them.  ]\Iuch  difficulty  is  often  obviated  when  an 
infant  has  become  accustomed  to  taking  food  from  an  artificial  nipple. 
Where  a  mother's  milk  absolutely  disturbs  her  baby  we  should  have 
no  hesitation  in  removing  the  infant  temporarily  from  the  breast  and 
placing  it  upon  a  low  formula  such  as  it  may  be  reasonably  sure  to 
digest,  pumping  and  massaging  the  breast  pending  resumption  of  the 
nursing.  The  risk  of  digestive  disturbance  or  of  slight  loss  of  weight, 
if  we  begin  with  a  very  weak  food,  is  usually  less  than  from  continuing 
the  breast  milk.  Such  acute  disturbances  are,  however,  comparatively 
rare. 


102  IXFAXT   FKEDIXG 


DISTURBANCES  OF  BREAST-FED  INFANTS. 

Of  the  infants  presented  to  us  with  the  story  that  they  are  not  doing 
well  at  the  breast  the  majority  fall  into  two  classes:  (A)  those  whose 
nutrition  is  gootl,  showing  that  they  have  made  substantial  gains  since 
birth;  (B)  those  whose  nutrition  is  much  behind  that  of  the  normal 
breast-fed  child  of  the  same  age.  In  Class  A  the  good  nutrition  of  the 
infant  presages  prompt  improvement  under  a]jpropriate  treatment  as 
indicating  a  fair  supply  of  breast  milk,  and  the  vomiting,  poor  stools, 
disturbed  sleep,  etc.,  which  have  caused  anxiety,  will  usually  disap]K'ar 
with  riifid  retjulation  of  nursin*;  intervals  and  nursing  habits  and  atten- 
tion  to  the  mother's  health  and  diet.  AVeaning,  too,  often  proposed  in 
these  cases,  should  not  be  considered,  especially  if  the  infant  is  gaining 
in  weight.  Class  B  constitutes  the  more  difficult  cases,  since  the 
poor  nutrition  indicates  prol)al)ly  a  poor  and  insufficient  secretion  of 
breast  milk.  Yet  in  these  cases,  unless  the  mother's  health  definitely 
demands  weaning,  much  may  often  be  accomplished  in  improving  the 
milk  so  that  successful  nursing  may  be  carried  on  in  part  if  not  for 
all  of  the  infant's  feedings.  Scanty  breast  milk  is  not  necessarily  bad 
breast  milk,  and  the  importance  to  the  infant  of  the  maternal  milk  is 
so  great  that  for  many  reasons  it  should  not  be  withdrawn  if  avoidable. 
Such  infants  should  be  under  frequent  observation  and  be  weighed 
at  intervals  of  two  or  three  days  upon  scales  which  weigh  ounces. 
If  such  weighings  show  that  the  child's  weight  is  stationary',  or  that  it 
is  only  losing  an  occasional  ounce,  we  may  safely  await  the  effects  of 
the  nourishing  fluids  and  the  improved  diet  and  health  of  the  mother. 
Should,  however,  the  condition  of  the  infant  be  too  serious  and  its  loss 
of  weight  be  too  rapid,  then  from  two  to  four  suitable  l)ottles,  beginning 
with  a  weak  modification  of  cows'  milk, should  be  given  daily,  alternating 
with  the  breast,  and  the  infant  should  always  be  put  to  both  breasts  at 
each  nursing  in  order  that  the  stimulation  of  these  glands  by  the  child 
may  not  be  lessened.  As  the  mother's  milk  increases  the  number  of 
bottles  may  be  lessened  and  more  nursings  given.  In  a  fair  proportion 
of  such  cases  they  may  later  be  dropped  entirely,  ])ut  more  frecjuently 
we  are  satisfied  to  have  the  mother  nurse  the  infant  in  part  and  supple- 
ment her  efforts  by  the  requisite  number  of  bottles.  In  institutions 
provided  with  milk  laboratories,  where  usually  one  mother  nurses  two 
babies,  the  insufficient  supply  of  breast  milk  is  often  suj^plemented  by 
a  few  ounces  of  m()difi(>d  milk  given  immediately  aft(>r  each  nursing, 
the  infant's  appetite  regulating  the  amount  taken.  This  plan,  which 
works  well  in  institutions,  is  rather  too  cumliersome  for  use  in  the  home, 
since  it  involves  as  much  care  and  preparation  as  entire  artificial 
feeding;  therefore,  a  few  supplementary  bottles  replacing  the  same 
number  of  nursings  is  usually  adopted.  This  latter  method  has  also 
one  distinctive  advantage — namely,  that  when  bottles  and  breast  are 
alternated,  a  longer  interval  for  digestion  occurs  between  the  two  bottles 
and  there  is  decreascil  liabilitv  to  disturbance.     More  attention  than 


MATERNAL   FEEDING  103 

formerly  is  now  given  to  the  importance  of  conserving  even  a  limited 
amount  of  breast  milk,  provided  it  can  be  made  of  reasonaljle  quality, 
since  not  only  are  such  cliildren  relatively  less  liable  to  disease  than 
those  who  are  entirely  bottle-fed,  but  also  because, if  digestive  and  bowel 
disturbances  do  occur,  the  child  may  be  temporarily  nourished  with  the 
more  easily  digested  breast  milk.  So  great  is  the  importance  to  the 
infant  of  maintaining  the  physiological  relation  existing  between  mother 
and  infant  until  the  latter  part  of  the  first  year,  that  the  physician  who 
counsels  early  weaning  without  making  all  reasonable  efforts  to  enable 
the  mother  to  continue  nursing  successfully  is  assuming  a  grave  responsi- 
bility for  the  life  of  the  child.  Bottle-fed  children  not  only  suffer  more 
commonly  from  various  forms  of  malnutrition  and  digestive  disturbances, 
but  have,  as  a  rule,  distinctly  less  resistance  to  intercurrent  disease. 
Many  bottle-fed  infants  die  from  maladies  which  they  would  have  been 
able  to  survive  had  they  been  nursed.  Moreover,  during  disturbances 
attendant  upon  bottle  feeding  the  child  often  lays  the  foundation  for 
both  digestive  and  physical  difficulties  wliich  not  only  handicap  it  in 
later  childhood,  but  may  pursue  it  into  adult  life. 


SPECIAL  INFLUENCES   WHICH  AFFECT  THE  BREAST  MILK. 

Drugs. — The  more  abnormal  the  secretion  of  the  breast  the  greater  is 
the  liability  to  the  elimination  of  drugs  through  this  channel.  While  few 
definite  rules  can  be  laid  down,  such  a  possibility  should  be  always  kept 
in  mind.  Opium,  belladonna,  and  colchicum  are  especially  to  be  guarded 
against.  When  the  milk  is  poor  and  particularly  with  young  infants, 
mercury,  arsenic,  iodides,  bromides,  lead,  antimony  and  the  salicylates 
at  times  appear  in  the  milk,  especially  after  prolonged  administration. 
This  is  not  sufficiently  constant  to  be  relied  upon  in  attempting  to 
medicate  the  child  through  the  medium  of  the  mother.  Cathartics 
given  the  mother  at  times  act  upon  the  infant,  and  malt  beverages,  or 
any  considerable  ingestion  of  alcohol,  may  produce  disturbance. 

Menstruation. — The  return  of  the  menstrual  flow  constitutes,  as  a 
rule,  no  contraindication  to  a  continuance  of  lactation.  In  a  very  small 
proportion  of  cases  only  is  the  infant  disturbed,  and  in  these  it  is 
a  simple  matter  to  give  the  infant  an  easily  absorbed  substitute  and  to 
pump  the  breasts  for  a  few  days.  After  appearing  once,  it  may  be 
absent  for  several  months.  The  more  discomfort  and  nervous  disturb- 
ance the  mother  experiences  the  greater  the  liability  to  alteration  in  the 
secretion,  which  at  times  takes  the  form  of  low  fat  and  high  proteids, 
although  this  has  not  been  generally  established.  The  average  mother, 
however,  may  disregard  menstruation  and  continue  nursing  during  the 
period. 

Pregnancy. — The  occurrence  of  pregnancy  is  almost  universally 
accepted  as  an  indication  for  taking  the  child  from  the  breast.  The 
secretion  usually  suffers  both  in  c[uantity  and  quality  and  the  mother's 
reserves  are  needed  for  the  nourishment  of  the  fetus.    There  is,  however, 


1Q4  IXFAXT  FEEDIXG 

no  urgent  haste  in  the  matter,  if  the  infant  is  not  losing  weight,  so  that 
wt^ming  may  l)e  grathially  and  safely  accomplished.  Other  consider- 
ations, suc-h  as  the  presence  of  hot  weather  and  the  age  and  condition 
of  the  infant,  must  influence  our  decision,  but  as  soon  as  practicahle  the 
mother  should  be  enabled  to  devote  her  strength  entirely  to  her  new 
responsibilities. 

Nervous  Influences. — Every  observant  dairyman  will  inform  us  that 
the  milk  of  tiu-  cow  is  easily  afl'ected  by  nervous  influences.  This  is 
equally  true  of  the  nursing  mother,  whose  life  should,  so  far  as  possible, 
be  a  passive  one,  free  from  undue  excitement  or  mental  worries  and 
anxieties.  To  this  end  she  should  be  willing  to  surrender,  for  the  sake 
of  her  infant,  all  those  social  responsibilities  and  dissipations  which  are 
the  source  of  fatigue  and  nervous  wear  and  tear.  Instances  are  recorded 
where  intense  or  sudden  emotion,  fear,  grief,  mental  shocks,  and  mental 
and  physical  passion  have  induced  a  toxic  condition  of  the  milk,  with 
o-rave  disturl)ances  in  the  infant.  These  are  probably  the  result  of  some 
change  in  the  proteids  as  yet  undetermined,  since  the  symptoms — vomit- 
ing, diarrhea,  temperature,  stupor,  and  even  convulsions — are  similar  to 
those  from  other  toxins  of  proteid  origin.  Reasonable  diversion  should, 
on  the  other  hand,  not  be  denied  the  mother,  and  out-of-door  exercise 
without  fatigue  is  of  the  highest  importance. 

Minor  Acute  Illness. — The  flow  of  milk  may  be  decreased  by  temper- 
ature, but  the  lesser  temporary  ailments,  even  if  rather  acute,  do  not 
seriously  affect  the  milk,  and  at  most  call  for  temporary  removal  from 
the  breast. 

Severe  Acute  Illness. — Typhoid  and  other  prolonged  fevers  call  for 
cessation  of  nursing  and,  indeed,  often  dry  up  the  breasts.  Severe 
general  sepsis  in  the  mother  is  a  menace  to  the  infant,  owing  to  the 
presence  of  micro-organisms  in  the  maternal  circulation  and  the  milk; 
but  slight,  local  puerperal  infection  of  short  duration  constitutes  no  bar. 
In  case  of  abscess  of  one  breast  the  infant  should  not  be  allowed  to 
nurse  that  breast  when  suppuration  is  probable,  nor  when  pus  is  demon- 
strable to  the  eye  or  to  the  microscope.  Nursing  may  be  resumed  as 
soon  after  incision  as  the  cavity  shows  healthy  granulations  which  close 
the  milk-ducts.  The  infant  may  continue  at  the  sound  breast,  and  the 
affected  breast,  if  possible,  be  pumped  to  maintain  the  secretion.  Early 
incision  limits  tissue  destruction,  shortens  the  inflammatory  process,  and 
enhances  the  possibilities  of  a  useful  breast. 

Chronic  Illness. — Certain  maladies  of  the  parent  render  nursing 
inadvisable  in  the  interest  of  the  mother  or  the  child,  or  both.  vSuch  are, 
dementia,  epilepsy,  tuberculosis,  and  marked  all)uminuria.  In  the  two 
latter,  nursing  favors  the  progress  of  the  disease,  while  the  milk  secreted 
will  probably  be  of  inferior  quality.  In  tuberculosis  the  opportunities 
for  infection  of  the  infant  are  greatly  enhanced  l)v  close  association  with 
the  person  of  the  mother.  Danger  of  direct  infection  through  the  milk 
increases  with  the  advance  of  the  disease  and  the  consequent  liability 
of  the  occurrence  of  tuberculous  foci  in  the  mamm?e.  A  syphilitic  infant, 
on  the  contrarv,  is  more  liable  to  survive  if  nursed  by  its  mother,  who, 


WEAXIXG  105 

according  to  Colles'  law,  is  immune  to  the  disease.  A  wet-nurse,  however, 
should  always  be  free  from  any  suspicion  of  such  taint,  and  may  readily 
become  infected  by  nursing  a  syphilitic  child. 


WEANING. 

No  definite  rule  as  to  the  proper  time  for  weaning  a  child  can  be  laid 
down,  but  the  general  statement  may  be  made  that  with  the  average 
healthy  mother  in  America  it  should  be  undertaken  at  about  the  end 
of  the  first  year.  Few  mothers  can  nurse  their  children  to  advantage 
longer  than  this.  Many,  on  the  other  hand,  cannot  maintain  a  satisfac- 
tory supply  so  long.  In  the  latter  case  I  have  already  recommended 
measures  for  supplementing  the  breast  with  bottle  feedings,  and  in 
such  instances  weaning  is  accomplished  easily,  since  the  gradual 
decrease  of  breast  milk  leads  to  the  giving  of  more  and  more  bottle 
feedings.  If  we  can  choose  the  time  of  weaning,  this  may  then  be  from 
the  ninth  to  the  twelfth  month,  but  preferal)ly  not  in  the  hot  months 
of  the  year,  for  in  midsummer  it  is  better  to  defer  the  completion  of 
weaning  a  few  weeks  until  the  cooler  days  of  early  autumn,  giving, 
perhaps,  two  bottles  daily  to  eke  out  the  breast  milk.  At  such  a  time 
even  a  stationary  weight  without  loss  should  not  deter  us  from  waiting 
two  or  three  wrecks,  since,  if  digestive  disturbance  can  be  avoided, 
children  rapidly  make  up  their  weight  on  the  new  food  in  the  fall  months, 
and  in  the  event  of  illness  we  have  the  breast  milk  to  fall  back  upon 
temporarily.  In  the  late  spring  it  may  be  best  to  get  the  child  accus- 
tomed to  taking  one  or  two  bottles  a  day  before  the  hot  weather  super- 
venes, if  the  breast  milk  will  probably  have  to  be  withdrawn  before 
the  fall. 

The  keynote  of  safe  weaning  is  that  the  process  be  gradual,  and  also 
to  keep  in  mind  the  fact  that  cows'  milk  is  a  different  fluid,  which  the 
child  must  be  trained  to  digest.  To  this  end  we  must  begin  with  a  low 
formula  for  a  child  of  nine  months  or  one  year  old,  not  exceeding  1  per 
cent,  of  proteids,  and  for  younger  children  0.50  to  0.75  per  cent,  pro- 
teids,  increasing  these  promptly  as  the  stools  show  proper  digestion. 
(See  page  141.)  Such  formulae  should  at  first  be  given  like  supplemen- 
tary feedings,  once  or  twice  a  day,  and,  when  the  formula  has  been  raised 
to  one  fitted  for  the  age,  others  are  added,  one  after  the  other,  until  the 
breast  is  largely  supplanted  by  the  bottle.  As  less  demands  are  made 
upon  the  breast  its  secretion  usually  disappears  without  trouble.  "\"\  ith 
older  children  the  time  of  weaning  is  the  time  for  the  introduction  of 
cereals  into  the  diet,  and  these  are  best  incorporated  into  the  diet  in  the 
form  of  barley,  oatmeal,  or  granum.  Some  children  can  undoubtedly 
soon  be  brought  to  take  plain  milk,  but  in  many  cases  this  is  not  as 
easily  digested  as  that  diluted  one-third  to  one-fifth  with  a  cereal  gruel, 
and  there  is  an  advantage  to  be  gained  from  the  use  of  cereals  at  this 
time  and  in  this  form.  Since  milk  is  to  be  for  many  months  the  basis  of 
the  diet,  and  since  children  without  question  will  drink  more   from  a 


106  IMAXr  FEEDISG 

bottle  than  from  a  cup  or  glass,  the  bottle  is  preferable  if  the  child  can 
be  induced  to  take  it.  Here,  a^'ain,  the  cliihl  should  not  be  limited  by 
the  size  of  the  usual  S-ounce  (250  c.c.)  feeiling  l)ottle,  but  9  to  12  ounces 
(280  c.c.  to  375  c.c.)  should  be  given  from  a  larger  bottle,  according  to 
the  ao-e.  In  suitable  cases  broths  or  l)eef-juice  maybe  given  once  daily. 
In  this  wav  the  weaned  child  gratlually  takes  up  the  diet  suitable  for  the 
second  vear. 


CHAPTER   VII. 

COWS'  ^LILK. 

The  practitioner  who  to-day  wishes  to  become  expert  in  modern 
infant  feeding  must  necessarily  have  a  good  general  knowledge  not  only 
of  the  chemistry  and  bacteriology  of  cows'  milk,  but  oftentimes  be  able 
to  advise  intelligently  concerning  its  production,  since  the  solution  of 
many  of  the  problems  to  be  met  with  is  directly  based  upon  these  factors. 
The  dairy  interests  of  the  world  have  assumed  such  importance  among 
its  productive  resources  that  elaborate  studies  of  these  questions  have 
been  made  possible  under  governmental  and  university  auspices  in  this 
and  other  countries. 

Composition. — ^Nlilk  is  composed  principally  of  water,  fat,  sugar,  pro- 
teid  or  albuminoid  bodies,  and  mineral  matter.  The  fat  is  suspended 
as  a  fine  emulsion  with  the  other  elements,  and  is  a  mixture  of  several 
fatty  compounds.  By  far  the  largest  proportion  (92  percent.)  is  fixed 
and  non-volatile,  and  consists  of  glycerides  of  oleic,  stearic,  and  palmitic 
acids.  A  smaller  volatile  group,  of  which  the  most  important  is  butyric 
acid,  is  constant,  and  constitutes  but  8  per  cent.  Still  others  may  be 
derived  from  special  foods  consumed,  and  the  flavors  given  to  milk  by 
cabbage,  onions,  and  turnips  as  well  as  the  more  desirable  ones  imparted 
by  clover  and  grasses  are  due  to  such  volatile  fats. 

Proteids. — These,  sometimes  called  albuminoids,  are  casein  and  certain 
soluble  albuminous  bodies.  Casein  is  thrown  down  by  the  action  of 
rennet  and  also  by  weak  solutions  of  acids,  making  what  is  loosely  known 
as  the  curd.  The  soluble  proteids  consist  of  several  bodies  which  are 
not  influenced  by  either  rennet  or  weak  acids,  but  are  to  some  extent 
coagulated  by  heat,  forming  the  familiar  skin  on  boiled  milk.  They 
are  contained  in  the  whey  which  separates  from  the  paracasein  clot 
formed  by  rennet,  and  in  the  fluid  which  is  pressed  out  from  the  curds 
of  fully  soured  milk  known  as  cottage  cheese. 

In  older  books,  and  even  in  some  of  the  modern  ones,  the  terms 
lactalbumin,  lactoglobulin,  lactoprotein,  albumin,  caseoses,  albumoses, 
and  peptones  are  variously  applied  to  these  or  they  are  referred  to  as 
albumins.  In  these  pages  they  will  be  spoken  of  collectively  as  the 
soluble  proteids  of  milk.  This  term  will  also  be  applied  to  the  proteids 
remaining  in  solution  in  whey,  in  the  clear  fluid  which  separates  from 
the  coagulum  of  sour  milk,  and  after  the  precipitation  of  the  casein  in 
digestion. 

The  analytical  methods  devised  thus  far  for  the  proteids  of  milk  give 
only  approximately  accurate  quantitative  results.  In  addition  to  the 
proteid  bodies  already  mentioned  there  is  another  analogous  to  mucin. 

(107) 


108  IXFAXT   FEEDING 

This  is  usually  called  Storch's  mucoid  piotcid,  and  is  profoundly  affected 
by  lime-water  and  other  stronji;  alkalies,  which  cause  it  to  swell  and 
become  viscid,  thus  visibly  tliickenini>;  the  milk.  It  is  not  atfected  by 
non-alkaline  antacids,  such  as  chemically  pure  bicarbonate  of  soda. 

Sugar. — The  lactose,  or  milk-sugar,  is  held  in  solution.  It  has  the 
same  chemical  formula  as  cane-sugar,  but  is  distinctly  less  sweet  to 
the  taste. 

Ash.^The  mineral  matters  of  the  milk  are  designated  in  analyses  as 
the  ash.  They  are  chiefly  in  solution  and  consist  in  large  part  of  phos- 
phates of  calcium  and  potassium,  chlorides  of  potassium  and  sodium, 
and  small  (juantities  of  phosphates  of  iron  and  manganese. 

Water. — ^Water  constitutes  a  large  proportion  of  milk,  being  from 
84  j)er  cent,  to  SS  per  cent,  of  the  whole. 

Milk  also  contains  very  small  (juantities  of  other  bodies,  of  less 
imj)ortance  to  the  practitioner,  such  as  citric  acid,  lecithin,  and  certain 
enzymes  having  the  property  of  slightly  digesting  milk.  The  foregoing 
constituents  of  cows'  milk  vary  widely  in  different  specimens.  The 
variations  are  dej)en(lent  upon  tlic  country,  the  breed  of  cattle,  the  period 
of  lactation,  the  diet,  the  time  of  day,  and  the  intervals  between  milkings. 


VARIATIONS  IN  MILK. 

A  brief  discussion  of  the  variations  in  cows'  milk  will  be  instructive. 
If  the  interval  between  the  daily  milkings  differ  in  length,  the  longer 
period  will  give  a  lower  percentage  of  fat  in  the  milk,  since  some  of  the 
fat  is  reabsorbed  during  its  retention  in  the  udder.  This  is  likewise 
true  of  the  human  breast  and  furnishes  a  cogent  reason  for  adhering  to 
regular  intervals  in  nursing.  Short  intervals  give  a  milk  too  rich  in  fat. 
The  composition  of  different  portions  of  the  cow's  milk  when  drawn 
from  the  udder  is  not  the  same  as  that  of  the  whole  milking  in  the  pail. 
The  first  milk  drawn  (foremilk)  contains  the  least  fat,  often  less  than 
2  per  cent.;  while  that  drawn  last,  called  strippings,  may  reach  as  high 
a  percentage  as  10  per  cent.  The  other  solids  do  not  vary  materially 
during  milking.  Aside  from  the  above  factors,  the  variations  in  the 
composition  of  the  whole  milk  of  individual  cows  are  principally  due 
to  nervous  influences.  These  are  not  only  such  as  fright  and  worry,  but 
even  sudden  changes  in  the  food  of  highly  bred  cows  probably  act  in  this 
way  through  the  nervous  system  (Babcock).  The  less  highly  bred  and 
less  nervous  animals  are  not  so  readily  affected  by  any  change  and  the 
composition  of  tiieir  milk  is  more  uniform,  (iradual  changes  in  the  food 
do  not  materially  affect  the  milk  of  a  healthy  cow.  Proper  feeding  may 
increase  the  quantity  of  milk,  but  the  almost  unanimous  opinion  of  dairy 
experts  is  that  it  is  beyond  our  power  to  alter  the  character  or  composition 
of  a  healthy  cow's  milk  from  that  which  is  normal  for  the  individual 
cow  by  any  means  except  nervous  influences.  The  good  results  obtained 
in  changing  tlie  com])()sition  of  human  breast  milk  are  due  to  the  restor- 
ation of  healthful  conditions  and  the  removal  of  pernicious    nervous 


COWS'   MILK  109 

influences  which  allow  the  re-establishment  of  a  secretion  of  milk  which 
is  normal  for  that  mother. 

Possible  individual  variations  in  cows'  milk  are  equalized  by  mixing 
the  milk  of  a  herd.  The  composition  of  such  mixed  milk  remains  fairly 
constant  at  the  same  season  of  the  year.  That  of  different  herds  varies 
with  the  breed  of  the  cows  composing  the  herd,  the  fat  being  highest 
in  the  highly  bred  Jersey  and  Guernsey  stock.  In  general  the  milk  of 
a  well-cared-for  herd  of  good  grade  cows  is  to  be  preferred  for  infant 
feeding  to  that  of  fancy  stock  with  delicate,  nervous  organizations  and 
a  liigh  percentage  of  fat  in  the  milk. 

It  is  therefore  to  be  understood  at  the  outset  that  cows'  milk  as  pro- 
duced or  sold  has  no  fixed  composition,  the  local  laws  governing  its  sale 
being  adjusted  so  as  to  do  no  injustice  to  the  farmer  producing  only  a 
fair,  unadulterated  milk. 

From  a  large  series  of  analyses  made  by  Van  Slyke,  and  representing 
individual  milks  whose  fat  percentages  ranged  from  3  05  per  cent,  to 
5.25  per  cent.,  the  following  have  been  selected  to  show  the  composition 
of  poor,  medium,  and  rich  milks: 

Actual  Analyses  of  Poor,  Medium,  and  Rich  Milks. 

Poor  milk.  Medium  milk.        Rich  milk. 

Fat 3.05  4.05  5.00 

Total  proteids    .        .        ■      2.64{Ti^' ^^V.     n ««  3.45  Pf  3.99  P^ 

^  (.soluble  proteids,  0.66.  1 0.68  (-0.85 

Sugar  and  ash     .      .        .     5.91  5.59  5.64 

Water 88.40  86.91  85.37 

These  actual  analyses  are  much  more  instructive  to  the  practitioner 
than  the  usual  tables  which  contain  averages  made  by  combining  the 
results  of  many  hundreds  or  thousandsof  analyses  of  milks  of  all  qualities. 
The  above  table  shows  the  relative  percentages  of  the  total  proteids 
and  their  component  parts — casein  and  soluble  proteids — in  specimens 
of  milk  which  contained  3  per  cent.,  4  per  cent.,  and  5  per  cent,  of  fat. 
The  sugar  and  ash  are  calculated  together  in  these  tables,  but,  since  the 
ash  of  milk  is  known  to  be  fairly  constant  at  0.70  to  0.75,  the  percentage 
of  milk-sugar  (lactose)  in  milk  can  be  set  down  at  about  5  per  cent.  In 
general  it  may  be  said  that  the  sugar  and  ash  are  fairly  constant  and 
the  fat  and  proteids  variable  factors.  As  a  rule,  the  amount  of  proteid 
rises  and  falls  with  the  amount  of  fat,  but  increase  of  fat  beyond  4.5 
per  cent,  does  not  involve  a  proportionate  increase  of  proteids. 

The  practitioner  will,  if  possible,  usually  choose,  in  preference  to  all 
others,  a  good  milk  containing  about  4  per  cent,  fat,  which  may  be 
determined  with  the  Babcock  milk-testing  machine.  A  table  constructed 
upon  this  basis  would  be  as  follows: 

Averages  of  Good  Milk  Containing  4  Per  Cent.  Fat. 

Fat 4.00 

Total  proteids 3.50 

Sugar         ....,..., 5.00 

Ash 0.70 

Water 86.80 


no  IXFAXT   FEEDING 


BACTERIAL  CONTAMINATION  OF  MILK. 

^Illk  is  one  of  the  favorable  culture  media  at  certain  temperatures 
for  tiie  growth  of  bacteria.  While  milk  when  .secreted  by  a  healthy 
cow  is  germ  free,  bacteria  are  always  present  in  the  larger  ducts, 
to  which  they  [)enetrate  from  without.  The  number  in  the  milk  may 
be  largely  reduced  by  rejecting  the  first  few  streams  of  milk,  but  the 
chief  contamination  occurs  after  it  leaves  the  udder.  The  universality  of 
bacterial  occurrence  and  the  startling  rapidity  of  bacterial  growth  and 
multiplication  are  exceedingly  difficult  matters  to  grasp  without  actual 
personal  experience  in  the  laboratory,  and  their  importance  is  but  imper- 
fectly realized  l)ythe  lay  mind, to  which  the  subject  is  necessarily  a  vague 
and  confused  one.  It  is  only  when  these  questions  come  to  affect  the 
profit  or  loss  of  the  dairy  business  that  an  intelligent  and  practical 
interest  can  be  aroused.  Bacteria  are  now  definitely  known  to  be 
vegetable  organisms.  In  those  forms  which  are  spore  bearing  life  is 
much  less  easily  destroyed  by  extremes  of  temperature.  Raj)id  develop- 
ment is  checked  by  low  temperatures.  Freezing  reduces  the  number 
of  the  bacteria,  but  does  not  kill  all,  especially  the  spore-bearing  forms, 
and  upon  thawing  they  again  become  active.  Growth  and  midti])li- 
cation  proceed  most  rapidly  in  warm  media,  but  extreme  heat  kills  at 
a  temperature  varying  with  the  resistance  of  the  individual  bacterium. 
It  may  be  said  of  most  of  the  usual  bacteria  in  milk  that  growth  is 
checked  at  a  temperature  below  40°  to  50°  F.,  is  most  favored  by  a  temper- 
ature of  80°  to  100°  F.,  again  decreases  at  105°  to  110°  F.,  and  with  the 
exception  of  the  spore-l)earing  forms  have  a  thermal  death  point  of  130°  to 
140°  F.  in  licjuids.  Spores  may  re(|uire  the  action  of  superheated  steam 
to  kill  them.  Not  only  does  milk  inevitably  contain  some  bacteria  which 
have  gained  access  to  the  ducts  despite  the  rejection  of  the  first  streams, 
but  bacteria  which  are  practically  onuiipresent  may  be  added  in  every 
phase  of  the  milking  and  subsequent  handling  of  the  milk  as  carried 
out  under  ordinary  conditions. 

No  particle  of  matter,  however  small,  seems  to  be  free  from  germ  life. 
Dirt,  fecal  matter,  hair,  the  floating  dust  of  the  barn,  the  surface  of  the 
milker's  hanfls  and  clothes,  receptacles  for  milk,  even  if  apparently  clean, 
all  furnish  their  quota.  Not  only  does  the  active  exercise  of  milking 
dislodge  dust,  dirt,  and  dandruff  from  the  cow,  which  may  fall  into  the 
pail,  while  the  han<ls  and  clothing  of  the  milker  contribute  their  share; 
but  particles  of  dust  in  the  air,  which  are  much  increased  by  the  manipu- 
lation of  dry  fodder  and  bedding,  constantly  settle  into  the  milk-pail, 
The  dust  in  the  air  is  considercfl  one  of  the  minor  factors  only,  though 
Harrison's  experiments  with  culture  plates  showed  that  in  one  minute, 
during  the  process  of  bedding  down,  from  12,000  to  43,000  bacteria 
settled  on  a  surface  equal  to  that  of  a  12-inch  milk-pail,  while  an  hour 
before  bedding  a  similar  series  of  cultures  showed  from  4S3  to  2370. 

Housing  the  cow  in  a  barn  away  from  all  hay  and  fodder,  keeping  the 
cow's  body  and  stable  free  from  filth  and  dust,  cleansing  and  dampening 


COWS'  MILK  111 

the  udder  and  teats  before  milking,  washing  the  hands  before  milking, 
rejecting  a  small  part  of  the  foremilk,  and  sterilization  of  the  milk 
receptacles  and  utensils  as  now  practised  in  the  best  dairies,  reduce 
vastly  the  germ  content  of  the  milk,  and  Backhaus  considers  that  these 
measures  will  easily  give  only  ^wo  of  the  number  of  germs  in  milk 
produced  in  the  usual  way.  The  subsequent  care  of  the  milk  calls  for 
straining  and  rapid  cooling,  with  the  same  precautions  against  con- 
tamination. Aeration,  formerly  considered  necessary  to  remove  animal 
odors  from  the  milk,  is  now  thought  to  be  sufficiently  accomplished 
during  milking,  thus  avoiding  an  additional  manipulation  with  its 
attendant  risks.  Straining  removes  the  coarser  particles  of  dirt,  but 
not  that  which  has  been  dissolved  in  the  milk  with  its  bacteria. 
Rapid  cooling  limits  the  multiplication  of  germ  life,  which  goes  forward 
with  startling  rapidity  until  a  sufficiently  low  temperature  has  been 
reached.  This  temperature  must  be  maintained  continuously  during 
all  the  phases  of  transportation  and  distribution,  since  growth  is  at  once 
accelerated  if  the  temperature  is  allowed  to  rise.  Bottling  at  the  farm 
in  sealed,  sterile  containers  is  the  only  guarantee  against  contamination 
en  route. 

Certified  Milk. — The  education  of  the  medical  profession  and  the 
laity  with  reference  to  the  advantages  of  clean  milk  of  low  bacterial 
content  has  led  to  the  establishment  in  various  places  of  systems  by 
which  local  health  boards  or  duly  organized  groups  of  physicians  have 
undertaken  to  place  the  seal  of  their  approval  upon  certain  dairies 
whose  milk  comes  up  to  a  rec}uired  standard  of  cleanliness. 

Such  milk  bears  a  label,  and  may  be  known  by  some  name  such  as 
"certified  milk."  In  other  localities,  certain  large,  private,  model  dairies 
have  created  their  own  reputation  for  the  purity  of  their  milk,  which 
is  borne  out  by  repeated  bacteriological  tests. 

Since  the  physician  may  at  any  tim.e  be  called  upon  to  pass  judgment 
upon  the  conditions  under  which  milk  is  produced,  or  to  give  instructions 
which  shall  safeguard  milk  which  is  to  be  used  in  infant  feeding,  certain 
abstracts  from  the  directions  issued  by  the  Milk  Commission  of  the 
Medical  Society  of  the  County  of  New  York,  which  certifies  milk  which 
comes  up  to  its  requirements,  are  here  given. 

"  Rules  for  Production  of  Certified  Milk. — The  most  practicable  standard 
for  the  estimation  of  cleanliness  in  the  handling  and  care  of  milk  is  its 
relative  freedom  from  bacteria. 

"  The  Commission  has  fixed  upon  a  maximum  of  30,000  germs  of  all 
kinds  per  cubic  centimetre  of  mJlk,  which  must  not  be  exceeded  to 
obtain  the  endorsement  of  the  Commission.  This  standard  must  be 
attained  solely  by  measures  directed  toward  scrupulous  cleanUness, 
proper  cooling,  and  prompt  delivery. 

"  The  milk  certified  by  the  Commission  must  contain  not  less  than  4 
per  cent,  of  butter-fat  on  the  average,  and  have  all  other  characteristics 
of  pure,  wholesome  milk. 

"  Milk  must  not  be  sold  as  certified  more  than  twenty-four  hours  after 
its  arrival  in  New  York  City. 


112  IXFAXT   FEKDISG 

"The  required  conditions  are  us  follows: 

"  1.  The  Bakxyard. — The  barnyard  should  be  free  from  manure  and 
well  drainetl,  so  that  it  may  not  harbor  stagnant  water.  The  manure 
which  collects  each  day  should  not  be  piled  close  to  the  barn,  but  should 
be  taken  several  hundred  feet  away,  if  these  rules  are  observed,  not 
only  will  the  barnyard  be  free  from  objectionable  smell,  which  is  an 
injury  to  the  milk,  but  the  number  of  flies  in  summer  will  be  considerably 
diminished. 

"  These  flics  arc  an  clement  of  danger,  for  they  are  fond  of  both  filth 
and  milk,  and  are  liable  to  get  into  the  milk  after  having  soiled  their 
boilies  and  legs  in  recently  visited  filth,  thus  carrying  it  into  the  milk. 

"  Flies  also  irritate  cows,  and  by  making  them  nervous  reduce  the 
amount  of  their  milk. 

"  2.  The  Stable. — In  the  stable  the  principles  of  cleanliness  must  be 
strictly  observed.  The  room  in  which  the  cows  are  milked  should  have 
no  storage  loft  above  it;  where  this  is  not  feasible  the  floor  of  the  loft 
should  be  tight,  to  prevent  the  sifting  of  dust  into  the  stable  beneath. 

"  The  stal)lcs  should  l)e  well  ventilated,  lighted,  and  drained,  and  should 
have  tight  floors,  preferably  of  cement,  never  of  dirt. 

"  They  should  be  whitewashed  inside  at  least  twice  a  year,  unless  the 
walls  are  painted  or  of  smooth  cement  finish,  which  can  be  washed 
frecjuently. 

"  The  air  should  always  be  fresh  and  without  bad  odor.  A  sufficient 
number  of  lanterns  should  be  provided  to  enable  the  necessary  work  to 
be  properly  done  during  the  dark  hours.  The  manure  should  be 
removed  twice  daily,  except  when  the  cows  are  outside  in  the  fields  the 
entire  time  between  the  morning  and  afternoon  inilkino;s.  The  manure 
gutter  must  Ijc  kept  in  a  sanitary  condition.  All  sweeping  must  be 
finished  before  the  grooming  of  the  cows  begins,  so  that  the  air  may  be 
free  from  dust  at  the  time  of  milking. 

"There  should  be  an  adecjuate  supply  of  water,  warm  and  cold,  and 
the  necessary  wash-basins,  soap,  and  towels. 

"  3.  AYater  Supply. — The  whole  premises  used  for  dairy  purposes,  as 
well  as  the  barn,  must  have  a  supply  of  water  absolutely  free  from  any 
danger  of  pollution  with  animal  matter,  and  sufficiently  abundant  for 
all  purposes  and  easy  of  access. 

"  4.  The  Cows. — Xo  cows  will  be  allowed  in  the  herd  furnishing 
certified  milk  except  those  which  have  successfully  passed  a  tuberculin 
test.  All  must  be  tested  at  least  once  a  year  by  a  veterinarian  approved 
by  the  Milk  Conmiission.  Any  animal  suspected  of  being  in  bad  health 
nmst  be  promptly  removed  from  the  herd  and  her  milk  rejected.  Do 
not  allow  the  cows  to  be  excited  by  hard  driving,  abuse,  loud  talking, 
or  any  unnecessary  disturbance. 

''Feed. — Do  not  allow  any  strongly  flavored  food,  like  garlic,  to  be 
eaten  by  the  cows. 

"  When  ensilage  is  fed  it  must  be  given  in  only  one  feeding  daily,  and 
that  after  the  morning  milking,  and  the  full  ration  shall  consist  of  not 
more  than  twenty  pounds  daily  for  the  average-sized  cow.     When  fed 


COWS'   MILK  113 

in  the  fall  small  amounts  must  be  given  and  the  increase  to  the  full 
ration  must  be  gradual. 

"  Corn-stalks  must  not  be  fed  until  after  the  corn  has  blossomed,  and 
the  first  feedings  must  be  in  small  amounts  and  the  increase  must  be 
gradual. 

"  If  fed  otherwise,  ensilage  and  corn-stalks  are  liable  to  cause  the  milk 
to  affect  children  seriously. 

"  Cleaning. — Groom  the  entire  body  of  the  cow  daily.  Before  each 
milking  wash  the  udder  with  a  cloth  used  only  for  the  udders,  and  wipe 
it  with  a  clean,  dry  towel.  Never  leave  the  udder  wet,  and  be  sure  that 
the  water  and  towel  used  are  clean.  The  tail  should  be  kept  clean  by 
frequent  washing.  If  the  hair  on  the  flanks,  tail,  and  udder  is  clipped 
close  and  the  brush  on  the  tail  is  cut  short  it  will  be  much  easier  to  keep 
the  cow  clean. 

"  The  cows  must  be  kept  standing  after  the  cleaning  until  the  milking 
is  finished.    This  m.ay  be  done  by  a  chain  or  a  rope  under  the  neck. 

"  5.  The  Milkers. — The  milker  must  be  personally  clean.  He  should 
neither  have  nor  come  in  contact  with  any  contagious  disease  while 
employed  in  handling  the  milk.  In  case  of  any  illness  in  the  person  or 
family  of  any  employe  in  tlie  dairy,  such  employe  must  absent  himself 
from  the  dairy  until  a  physician  certifies  that  it  is  safe  for  him  to 
return. 

'■  In  order  that  the  ]Milk  Commission  may  be  informed  as  to  the  health 
of  the  employes  at  the  certified  farms,  the  Commission  has  had  postal 
cards  printed,  to  be  supplied  to  the  farms,  and  to  be  filled  out  and 
returned  each  week,  by  the  owner,  manager,  or  physician  of  the  farm, 
certifying  that  none  are  handling  the  milk  who  are  in  contact  with  any 
contagious  disease. 

"  Before  milking  the  hands  should  be  washed  m  warm  water  with  soap 
and  nail  brush  and  well  dried  Avith  a  clean  towel.  On  no  account  should 
the  hands  be  wet  during  milking. 

"  The  milkers  should  have  light-colored,  washable  suits,  including  caps, 
and  not  less  than  two  clean  suits  weekly.  The  garments  should  be  kept 
in  a  clean  place,  protected  from  dust,  when  not  in  use. 

"  Iron  milking  stools  are  recommended,  and  they  should  be  kept  clean. 

"  ^Milkers  should  do  their  work  quietly  and  at  the  same  hour  morning 
and  evenino-.  Jerkino-  the  teat  increases  materiallv  the  bacterial  con- 
tamination  of  the  milk  and  should  be  forbidden. 

"  6.  Helpers  Other  than  INIilkers. — i^ll  persons  engaged  in  the 
stable  and  dairy  should  be  reliable  and  intelligent.  Children  under 
twelve  should  not  be  allowed  in  the  stable  or  dairy  during  milldng,  since 
in  their  ignorance  they  may  do  harm,  and  from  their  liability  to  con- 
tagious diseases  they  are  more  apt  than  older  persons  to  transmit  them 
through  the  milk. 

"  7.  SiL\LL  Animals. — Cats  and  dogs  must  be  excluded  from  the 
stables  during  the  time  of  milking. 

'■  8.  The  Milk. — All  milk  from  cows  sixty  days  before  and  ten  days 
after  calving  must  be  rejected. 


114  IXFAXT  FEEDING 

"The  first  few  streams  from  eaeh  teat  should  be  discarded,  in  order 
to  free  the  milk-tkiets  from  the  milk  that  has  remained  in  them  for  some 
time  and  in  whieli  the  bacteria  are  sure  to  have  muUiphed  greatly.  If 
any  ])art  of  the  milk  is  bloody  or  strinn;y  or  unnatural  in  appearance,  the 
whole  (juantity  yielded  by  that  animal  must  be  rejected.  If  any  accident 
occurs  in  which  a  pail  becomes  dirty,  or  the  milk  in  a  pail  becomes  dirty, 
do  not  try  to  remove  the  dirt  by  straining,  but  put  aside  the  pail,  and  do 
not  use  the  milk  for  bottling,  and  use  a  clean  pail. 

'■  Remove  the  milk  of  each  cow  from  the  stable  innnediately  after  it  is 
obtained  to  a  clean  room  and  strain  through  a  sterilized  strainer  of 
cheese-cloth  and  absorbent  cotton. 

"  I'he  rapid  cooling  is  a  matter  of  great  importance.  The  milk  should 
be  cooled  to  45°  F.  within  an  hour  and  not  allowed  to  rise  above  that  as 
long  as  it  is  in  the  hands  of  producer  or  dealer.  In  order  to  assist  in 
the  rapid  cooling,  the  bottles  should  be  cold  before  the  milk  is  put 
into  them. 

"Aeration  of  milk  beyond  that  obtained  in  milking  is  unnecessary. 

"  9.  Utensils. — All  utensils  should  be  as  simple  in  construction  as 
possible,  and  so  made  that  they  may  be  thoroughly  sterilized  before 
each  using. 

"  Coolers,  if  used,  should  be  sterilized  in  a  closed  sterilizer,  unless  a 
very  high  temperature  can  be  obtained  by  the  steam  sent  through  them. 

"  Bottling  machines  should  be  madeentirelv  of  metal  with  no  rubber 
about  them,  and  should  be  sterilized  in  the  closed  sterilizer  before  each 
milking  or  bottling. 

"  If  cans  are  used,  all  should  have  smoothly  soldered  joints,  with  no 
places  to  collect  the  dirt. 

"  Pails  should  have  openings  not  exceeding  eight  inches  in  diameter, 
and  may  be  either  straight  pails  or  the  usual  shape  with  the  top  protected 
by  a  hood. 

"  Bottles  should  be  of  the  kind  known  as  'common-sense,'  and  capped 
with  a  sterilized  paraffined  paper  disk,  and  the  caps  authorized  by  the 
Commission. 

"  All  dairy  utensils,  including  the  bottles,  must  be  thoroughly  cleansed 
and  sterilized.  This  can  be  done  by  first  thoroughly  rinsing  in  warm 
water,  then  washing  with  a  brush  and  soap  or  other  alkaline  cleansing 
material  and  hot  water,  and  thoroughly  rinsing.  After  this  cleansing 
they  should  be  sterilized  by  boiling,  or  in  a  closed  sterilizer  with  steam, 
and  then  kept  inverted  in  a  place  free  from  dust. 

"  10.  The  Daiuy. — The  room  or  rooms  where  the  utensils  are  washed 
and  sterilized  and  the  milk  bottled  shoukl  be  at  a  distance  from  the 
house,  so  as  to  lessen  the  danger  of  transmitting  through  the  milk  any 
disease  which  may  occur  in  the  house. 

"The  bottUng-room,  where  the  milk  is  exposed,  should  be  so  situated 
that  the  doors  may  be  entirely  closed  during  the  bottUng  and  not  opened 
to  admit  the  milk  nor  to  take  out  the  filled  bottles. 

"  The  empty  cases  should  not  be  allowed  to  enter  the  bottling-room  nor 
should  the  washing  of  any  utensils  be  allowed  in  the  room. 


COWS'   MILK  115 

"The  workers  in  the  dairy  should  wear  white  washable  suits,  including 
cap,  when  handling  the  milk. 

"Bottles  must  be  capped  as  soon  as  possible,  after  filling,  with  the 
sterilized  disks. 

"11.  Examination  of  the  Milk  and  Dairy  Inspection. — In  order 
that  the  dealer  and  the  Commission  may  be  kept  informed  of  the  char- 
acter of  the  milk,  specimens  taken  at  random  will  be  examined  weekly 
by  experts  for  the  Commission,  at  the  Laboratory  of  the  Department  of 
Health,  the  use  of  the  laboratories  having  been  given  for  that  purpose. 

"  The  Commission  reserves  to  itself  the  right  to  make  inspections  of 
certified  farms  at  any  time  and  to  take  specimens  of  the  milk  for  exami- 
nation, and  to  impose  fines  for  repeated  or  deliberate  violations  of  the 
requirements  of  the  Commission. 

"  The  Commission  also  reserves  the  right  to  change  its  standards  in  any 
reasonable  manner  upon  due  notice  being  given  to  the  dealers. 

"  The  expenses  of  making  the  regular  milk  reports  and  the  inspections 
are  borne  by  the  dealers." 

Experience  has  shown  that  the  periodical  examinations,  which  include 
estimations  of  the  number  of  bacteria  per  cubic  centimetre  of  milk,  are 
necessary  not  only  for  control,  but  also  prove  a  great  incentive  at  the 
dairy  to  improve  the  technique  of  production  so  as  to  lower  the  bacterial 
count.  Under  the  best  conditions  of  production,  milk  still  contains 
several  thousands  of  bacteria  per  cubic  centimetre,  and  while  this  is  a 
vast  improvement  over  conditions  which  allow  of  the  sale  of  milk  in 
cities  which  contain  at  some  seasons  of  the  year  anywhere  from  1 ,000,000 
to  85,000,000  bacteria  per  cubic  centimetre,  sight  should  never  be  lost 
of  the  fact  that  bacteria  and  their  action  must  always  be  reckoned  with  in 
the  consideration  of  milk  as  a  food.  Many  of  these  bacteria  are  innocuous, 
others  have  a  fermentative  or  putrefactive  action,  while  still  others  are 
pathogenic  and  capable  of  producing  disease.  The  degree  of  danger 
which  arises  from  the  use  as  food  of  the  milk  of  a  tuberculous  cow  is 
still  a  mooted  question;  but  since  undoubted  instances  of  the  trans- 
mission of  tuberculosis  by  this  means  have  been  recorded,  ordinary 
common-sense  dictates  that  tuberculosis  should  be  eliminated  from  the 
herds  and  the  milk  of  such  cattle  rejected.  With  tuberculosis  of  the 
udder  the  tubercle  bacilli  may  be  demonstrated  in  the  milk.  The 
use  of  the  tuberculin  test  to  eliminate  diseased  animals  from  the  herd 
should  be  encouraged. 

Epidemics. — Epidemics  of  aphthous  stomatitis  have  been  traced  to 
the  drinking  of  milk  from  cows  suffering  from  foot-and-mouth  disease. 
Tetanus,  anthrax,  and  hydrophobia  are  other  diseases  of  cattle  to  which 
man  is  liable,  but  the  only  rule  for  safety  is  to  reject  the  milk  of  any 
cow  which  shows  evidence  of  illness.  Epidemics  of  typhoid  fever, 
scarlet  fever,  diphtheria,  and  cholera  from  contamination  of  the  milk  by 
persons  employed  in  its  handling,  or  from  water  used  in  diluting  it  or 
for  washing  the  utensils,  are  fully  authenticated. 

Bacteria  of  Putrefaction. — There  remain  to  be  considered  the  bacteria 
which  gain  access  to  the  milk  in  the  usual  way  during  its  production. 


110  L\FA\'T   FKEDISG 

These,  which  are  of  many  different  kinds,  are  rouj^lily  divided  into  pntre- 
factive  and  fermentative  groups.  The  former — the  j)utr(.'factive — act 
n})()n  the  proteids,  and  certain  of  i\\v\\\  may  occasionally  form  toxins 
in  tiie  milk  before  it  is  consumed,  which,  when  taken  into  the  system, 
cause  severe  and  even  fatal  poison.  Such  a  sul)stance  isolated  by 
\"au<>;han  has  been  called  tyrotoxicon.  Other  putrefactive  bacteria  may 
find  sj)ecial  conditions  for  their  development  after  reachin<i;  the  di<^estive 
tract,  especially  if  digestion  is  disturbed.  This  is  doubtless  the  source  of 
some  of  the  more  intense  cases  of  the  so-called  sunnner  diarrhea  o'i 
young  children,  and  since  the  j)roteids  of  milk  furnish  a  suitable  ma- 
terial for  the  develoj^ment  of  such  bacteria  and  their  elaborated  toxins, 
the  rule  is  now  al)solute  to  stop  milk  in  any  form  and  to  evacuate  its 
residue  thoroughly  from  the  bowel  upon  the  appearance  of  diarrhea. 

Bacteria  of  Fermentation. — Of  the  fermentative  forms  the  so-called 
lactic-acid-producing  bacteria  are  tlie  most  im])ortant.  Although  when 
the  milk  is  drawn  these  may  be  in  the  minority,  ordinary  conditions  to 
which  milk  is  subjected  are  so  much  more  favorable  to  their  growth  that 
they  crowd  the  others  into  the  background,  and  are  soon  more  than 
90  per  cent,  of  the  bacteria  in  the  milk.  Their  rapid  growth  is  favored 
l)y  the  presence  of  the  milk-sugar,  which  they  transform  into  lactic 
acid.  This  lactic  acid  increases  with  the  multiplication  of  the  bacteria 
until  it  causes  coagulation  of  the  casein,  and  the  most  common  change, 
therefore,  in  milk  is  that  of  souring.  Such  a  change  renders  it  unfit  for 
infant  feeding,  although  it  is  often  easily  digested  by  adults.  Souring 
of  milk  formerly  ascribed  to  thunder-showers  can  only  be  explained  by 
the  fact  that  the  atmospheric  conditions  and  tempcratiu'c  before  the 
storm  favor  this  fermentation. 

Not  only  do  acids  form  definite  chemical  products  with  calcium  ])ara- 
casein  (calcium  casein  clotted  by  rennet),  but  acids,  including  lactic 
acid,  may  act  upon  calcium  casein,  directly  forming  l)oth  free  casein 
and  a  compound  of  casein  and  acid.  Lactic  acid  in  small  amount  does 
not  at  first  precipitate  the  casein,  but  as  it  increases,  and  especially  if 
the  milk  is  warmed,  there  appear  in  the  milk  fine  fiocculi  which  are  chiefly 
free  casein.  When  the  lactic  acid  reaches  about  0.0  to  0.7  per  cent, 
(total  acidity  O.S  to  0.0  per  cent.)  the  milk  forms  a  semisolid  mass  or 
clal)ber,  which  is  chiefly  lactate  of  casein,  and  the  growth  of  the  lactic 
bacteria  soon  ceases.  Before  the  acid  has  increased  to  the  point  of  pre- 
cipitating the  casein,  rennet  may  still  act  upon  the  calcium  casein,  form- 
ing calcium  paracasein,  which  with  the  acid  present  is  changed  into  free 
paracasein  and  lactate  of  paracasein.  These,  like  all  forms  of  para- 
casein produced  by  the  action  of  acids,  are  tough,  slowly  contracting 
masses.  When,  however,  lactic  acid  has  precipitated  the  calcium  casein 
in  soft  masses  of  free  casein  and  lactate  of  casein,  rennet  can  no  longer 
act  upon  these  and  the  denser  paracasein  compounds  cannot  be  formed. 
The  products  of  calcium  casein  and  acids,  being  softer  than  those  of 
calcium  paracasein  and  acids,  are  then  usually  more  digestible,  but 
products  of  either  with  lactic  acid  do  not  apparently  differ  materially 
in  their  relative  digestibility  from  similar  combinations  formed  by  hydro- 


COWS'   MILK  117 

chloric  acid.  Fully  soured  milk,  clabber,  and  buttermilk  are  readily 
digestible  for  the  adult  because  tough  paracasein  products  cannot  be 
formed  from  them,  since  rennet  does  not  affect  them.  Both  kumyss 
and  zoolak,  which  are  the  products  of  types  of  fermentation  with  the 
production  of  lactic  acid,  contain  soft  flocculi  precipitated  by  the  acid, 
and  probably  owe  their  digestibility  largely  to  the  same  principle. 

The  presence  of  milk-sugar  favors  the  production  of  lactic  acid,  and 
the  latter  also  holds  the  activity  of  the  putrefactive  groups  of  bacteria 
in  check. 

Heating  milk  to  a  sufficiently  high  temperature  to  destroy  the  lactic- 
acid-forming  bacteria  does  not  completely  destroy  other  forms  in  the 
milk  which  contain  spores.  Such  milk  undergoes  different  changes 
through  the  action  of  these  unkilled  spore-bearing  forms,  which  would 
have  been  prevented  from  developing  by  the  presence  of  the  lactic  acid 
forms.  These  produce  either  a  curdling  of  the  milk  and  subsequent 
digestion  of  the  proteids  or  digestion  without  curdling,  conditions  which 
are  brought  about  by  the  action  of  unorganized  ferments  or  enzymes  to 
which  the  bacteria  give  rise.  It  is  for  this  reason  that  such  heated  milk, 
although  it  will  not  sour  and  therefore  can  be  used  longer,  will  often 
develop  a  very  foul  odor  and  become  poisonous.  INIilk  which  has  been 
heated,  as  well  as  that  which  has  not  been  heated,  should  therefore  be 
kept  cool  if  it  is  to  be  used  as  an  infant's  food,  and  should  not  be  sub- 
jected to  warmth  for  a,ny  length  of  time. 


MILK  PRESERVATION. 

The  preservation  of  milk  which  is  to  be  used  as  the  food  of  infants  is 
of  the  highest  importance.  Since  the  changes  which  milk  undergoes  are 
in  direct  proportion  to  the  number  of  bacteria  which  it  contains,  it  does 
not  require  further  argument  to  demonstrate  that  a  clean  milk  which 
has  from  the  outset  contained  the  lowest  possible  number  of  germs  is 
vastly  preferable  to  a  milk  in  which  germs  already  present  in  large 
numbers  have  been  killed  or  held  in  check  by  artificial  methods.  Not 
only  are  the  constituents  of  the  milk  altered  by  the  presence  of  bacteria 
which  are  nourished  by  it  and  produce  in  their  growth  and  action  by- 
products which  may  be  both  foreign  and  hurtful,  but  in  the  case  at 
least  of  spore-bearing  forms  they  cannot  be  destroyed  without  seriously 
changing  the  nutritive  and  digestib/ie  properties  of  the  milk. 

The  necessity  of  securing  a  clean  milk  being  admitted,  it  is  still 
necessary  to  consider  methods  of  preservation,  since  milk  from  the  most 
unimpeachable  sources  still  contains  a  rather  formidable  number  of 
germs. 

Preservatives. — The  question  of  preservatives  can  be  dismissed  with 
a  few  words  of  unqualified  condemnation.  jNIilk  designed  for  the  feeding 
of  children  should  not  be  subjected  to  any  form  of  chemical- adulteration. 
Alkaline  antacids,  like  sodium  bicarbonate,  may  neutralize  acid  already 
formed  in  the  milk,  but  do  not  inhibit  the  growth  of  the  acid-forming 


118  IXFAXT   FKEDIXG 

bacteria,  but  instead  favor  it,  since*  1  por  cent,  lactic  acid  checks  growth. 
Sahcylic  acid,  boric  acid,  and  formaldehyde,  which  form  the  bases  of 
most  commercial  preservatives,  even  if  they  be  not  added  in  amonnts 
which  are  definitely  hurtful  (and  this  is  still  a  mooted  question),  have 
no  place  ainong  the  rcvjuirements  of  the  child.  In  many  foreign  countries 
where  the  jjassage  of  jnu'e  food  laws  camiot  be  retarded  by  the  cn])idity 
of  the  dealers  the  use  of  such  j)reservatives  is  absolutely  prohibited. 

Accepted  Measures  of  Preservation. — 'J  he  trend  of  the  best 
medical  opinion  at  the  present  day  is  undoubtedly  toward  the  use 
of  fresh,  clean,  unheated  milk  when  conditions  are  such  as  to  render 
this  safe.  Such  conditions,  however,  only  exist  during  the  cool 
months  of  the  year  with  milk  from  a  healthy  inspected  herd,  handled 
at  every  stage  with  the  utmost  attention  to  cleanliness,  kept  con- 
stantly at  a  temperature  below  40°  to  50°  F.,  and  used  at  or  near  its 
place  of  production  while  it  is  still  fresh.  Naturally,  this  combination 
can  only  obtain  in  the  country  and  towns  where  milk  is  su})])lie(l  from 
the  immediate  environment.  In  cities  milk  is  almost  invariably,  in  part 
at  least,  twenty-four  hours  old  when  it  reaches  the  consumer,  and, 
indeed,  some  of  it  often  thirty-six  or  forty-eight  hours  old.  It  must 
then  serve  for  twenty-four  hours  longer  or  until  the  next  day's  su])ply 
arrives.  Some  measure  must,  therefore,  be  adopted  to  check  the  already 
abundant  growth  of  bacteria  and  to  preserve  the  milk  from  souring. 
Three  inethods  are  in  general  use  for  this  purpose — pasteurization, 
sterilization,  and  boiling.  These  terms  are  much  more  indefinite  than 
is  generally  supposed,  since  temperatures  from  00°  to  75°  C.  (140° 
to  167°  F.)  are  recommended  for  pasteurization  for  various  periods  of 
time.  Sterilization  is  the  term  applied  to  heating  to  100°  C.  (212°  F.)  or 
generally  to  a  higher  point  for  different  lengths  of  time.  Boiling  is  often 
considered  to  begin  when  the  milk  rises  in  the  container  at  75°  to  85°  C. 
(107^  to  185°  F.),  but  it  actually  boils  at  about  101°  C,  Avith  the 
appearance  of  large  ])ubbles.  Some  of  the  differences  of  opinicm  con- 
cerning the  effects  of  these  methods  upon  the  milk  are  tloubtless  thus 
explained. 

Pasteurization. — Pasteurization  may  be  carried  out  in  various  ways. 
Theoreti(;ally  the  l)est  way  vv^ould  be  to  have  the  milk  pasteurized  at  the 
dairy  in  the  bottles  in  which  it  is  delivered  to  the  customer  before  the 
germs  have  had  an  opportunity  to  midtiply.  While  this  method  would  be 
preferable  for  children  old  enough  to  take  whole  milk  it  is  inapplicable  in 
the  majority  of  cases  where  the  milk  is  to  be  modified  at  the  home,  since 
the  necessary  handling  and  exposure  during  modification  would  r(>nder 
a  second  heating  advisable.  Another  and  even  more  grave  difficulty 
consists  in  the  previously  mentioned  fact  that  pasteurization  kills  the 
lactic-acid -producing  bacteria,  which  are  inimicable  to  other  forms,  and 
clears  the  wav  for  the  free  development  of  the  putrefactive  germs;  so 
that  such  miik,  unless  handled  with  the  greatest  care  and  kept  con- 
tinuously cool,  may  in  time  become  more  dangerous  than  if  it  had 
not  been  heated  at  all.  Pasteurization  was  at  first  popularized  in  this 
country  by  the  efforts  of  Dr.  11.  (J.  Freeman,  who  devised  a  practical  and 


COWS'   MILK 


119 


not  expensive  apparatus  for  home  use  known  as  the  Freeman  pasteurizer 
(Figs.  27  and  28),  in  which  the  number  of  nursing  bottles  required  for 


Fig.  27 


Freeman  pasteurizer. 
Fig.  28 


Freeman  pasteurizer. 


120  INFANT  FEEDING 

use  in  twenty-four  hours  are,  with  their  eontents,  raised  to  a  temperature 
of  GS°  C.  (155°  F.)  and  maintained  at  that  point  for  thirty  minutes.  A 
cheaper  apparatus  may  be  constructed  from  a  large  tin  i)ail  hohhng  a 
rack  for  the  nursing  l)()ttles,  tlie  cover  of  wliich  is  perforated  hy  a  hok' 
to  a(hnit  a  chemical  thermometer.  The  bottles  are  tli(>n  immersed  in 
water  up  to  their  necks  and  the  whole  heated  until  the  thermometer 
registers  75°  C.  (107°  F.),  when  it  is  moved  back  on  the  stove  and 
allowed  to  stand  twenty  mimites.  Again,  the  whole  supply  of  milk 
prej)ared  for  the  day's  feedings  may  be  placed  in  a  large,  glass  fruit-jar 
closed  by  a  cork,  through  which  passes  a  chemical  thermometer,  and  the 
jar  surrounded  by  water  and  heated  to  75°  C.  (107°  F.),  and  this  temper- 
ature maintained  twenty  minutes,  when  the  cork  is  replaced  by  a  cap  or 
a  plug  of  sterilized  cotton.  With  the  use  of  any  of  these  methods  the 
receptacles  containing  the  milk  should  be  removed  at  the  end  of  the 
period  of  pasteurization,  and  cooled  as  rapidly  as  possible  in  running 
water  and  then  placed  on  ice.  Placing  the  receptacle  directly  on  ice, 
without  pn^liminary  cooling,  wastes  ice,  and  there  is  a  longer  period 
(luring  which  the  milk  remains  warm,  thus  favoring  the  development  of 
the  unkillcd  sj)orcs. 

Sterilization. — Absolute  sterilization  of  milk  can  only  be  secured  by 
heating  to  points  considerably  above  100°  C  (212°  F.)  for  one  hour 
on  each  of  three  successive  days.  This  method  kills  the  bacteria  which 
germinate  in  the  intervals  from  the  latent  spores  which  have  remained 
uiuiffected.  Sterilization  as  ])ractised  in  the  home  is  never  com])lete, 
for  while  it  kills  the  living  germs  it  does  not  kill  the  spores.  Plowever, 
sterilization  at  100°  C.  (212°  F.)  for  ten  to  thirty  minutes  is  practically 
sufhcient  when  milk  is  to  be  used  within  the  following  forty-eight  hours. 
This  may  be  carried  out  by  boiling  the  whole  supply  in  a  saucepan  or 
doul)le  boiler;  or  the  separate  feedings  for  the  day,  contained  in  nursing 
bottles  stoppered  with  sterilized  non-absorbent  cotton  and  held  upright  in 
a  rack,  may  be  subjected  to  the  action  of  steam  in  an  Arnold  sterilizer,  or 
simply  boiled  by  ])lacing  the  rack  in  any  covered  receptacle  containing 
water.  An  intermediate  process  suitable  for  employment  among  classes 
where  but  little  time  for  the  care  of  the  milk  can  be  exacted,  and  one 
which  eml)races  some  of  the  advantages  claimed  for  both  pasteurization 
and  sterilization,  consists  in  bringing  the  milk  in  a  saucepan  or  double 
boiler  just  up  to  the  point  where  boiling  commences,  reinoving  it  from 
the  hot  (ire,  standing  it  for  twenty  minutes  in  a  warm  place,  cooling 
it  rapidly  in  water,  and  placing  it  on  ice  in  a  clean,  stoppered  jar  f)r 
bottle. 

The  relative  merits  and  demerits  of  pasteurization  and  sterilization, 
together  with  the  indications  for  their  employment,  may  be  summed  up 
as  follows: 

Pasteurization  and  Sterilization  Compared. — Pasteurization  does  not 
alter  the  taste  of  the  milk,  nor  change  the  chemical  constituents,  nor 
directly  affect  materially  the  digestibility;  while  it  kills  the  bacteria  of 
tuberculosis,  tyjihoid,  diphtheria,  cholera,  and  the  pathogenic  forms  of 
bacteria,  such  as  the  staphylococcus,  the  streptococcus,  and  bacillus  coli 


COWS'   MILK  121 

communis.  It  also  destroys  most  other  forms  which  are  to  be  found 
in  milk,  but  does  not  affect  the  spore-bearing  peptonizing  and  butyric- 
acid-forming  groups.  If  the  milk  is  subsequently  kept  properly  cool, 
it  is  sufficient  to  preserve  the  milk  two  or  three  days,  or  more  than 
ample  time  for  ordinary  use  in  infant  feeding.  In  an  indirect  way  pas- 
teurization may  definitely  influence  the  digestibility  of  the  casein  of 
cows'  milk.  The  quantity  of  tough  products  of  paracasein  and  acid 
formed  in  the  stomach  is  proportionate  to  the  total  amount  of  acids 
present.  Pasteurization  by  destroying  the  lactic  germs  prevents  the 
formation  of  lactic  acid,  so  readily  produced  in  milk,  especially  during 
the  summer  months.  This  allows  the  normal  acid  of  the  stomach  to 
form  its  own  amount  of  paracasein  products,  which  will  more  probably 
be  in  proportion  to  the  digestive  powers  and  the  amount  of  pepsin 
secreted.  Pasteurization  may  then  at  least  be  said  to  prevent  milk  from 
becoming  more  indigestible.  Furthermore,  the  action  of  rennet  is  slower 
and  more  imperfect  upon  pasteurized  milk. 

Some  of  the  changes  which  are  said  to  be  produced  in  milk  by  the 
higher  temperatures  included  in  the  term  sterilization  are  decomposi- 
tion of  lecithin  and  nuclein,  reduction  of  the  organic  forms  of  phosphorus, 
change  in  form  of  part  of  the  lactose,  greater  coalescence  of  the  fat 
globules,  coagulation  of  the  albumin  of  the  soluble  proteids,  which 
progresses  steadily  above  75°  C.  ( 1 67°  F. )  and  a  more  imperfect  action  upon 
the  casein  of  rennet,  pepsin,  and  pancreatin.  There  is  also  an  alteration  in 
the  taste.  It  would,  therefore,  seem  that  certain  vital  principles  are 
altered  or  destroyed,  and  the  claim  is  made,  with  reasonable  probability, 
that  its  exclusive  use  favors  the  development  of  anemia,  rickets,  scurvy, 
and  constipation.  Prolonged  heating  at  high  temperatures  should 
therefore  be  discouraged,  except  where  there  are  good  grounds  for  its 
use.  As  in  all  matters  pertaining  to  infant  feeding,  judgment  and  careful 
consideration  of  the  special  circumstances  should  enter  into  our  choice. 
Neither  method  should  be  made  a  fetish,  as  it  often  is  by  the  laity. 
Neither  makes  the  milk  directly  more  digestible  nor  lessens  one  iota  the 
necessity  for  proper  modification  for  the  infant.  The  sole  purpose  of 
these  methods  is  to  kill  dangerous  germs,  and  to  lengthen  the  time  during 
which  the  milk  may  be  safely  used  as  a  food.  Absolutely  fresh,  clean 
milk  kept  at  a  low  temperature  and  used  with  reasonable  promptness 
during  the  winter  months  requires  no  heating.  The  necessity  for 
pasteurization  arises  with  the  slightest  uncertainty  as  to  the  cleanliness 
of  milk,  the  healthiness  of  cows,  the  delay  before  consumption,  the 
advent  of  warm  weather,  and  where  milk  is  to  be  distributed  after 
modification  for  use  in  the  homes  of  the  poor,  where  there  is  always 
uncertainty  as  to  its  subsequent  care.  Sterilization  of  milk  is  indicated 
where  any  serious  doubt  exists  as  to  its  source,  when  it  is  to  be 
preserved  for  a  long  time,  as  on  a  journey  or  voyage,  and,  perhaps,  also 
where  it  is  to  be  distributed  in  the  hot  months  among  the  imorant  and 
careless  poor. 


122  IXFAXT  FEEDIXG 


CREAM. 


This  term,  .sifjnifyincr  the  more  concentrated  fatty  portion  of  milk, 
ha^  letl  to  much  confusion,  since  what  passes  for  cream  may  contain 
anywhere  from  S  per  cent,  to  40  per  cent.,  or  even  more,  of  butter-fat. 
Cream  raised  l)v  the  old  shallow-pan  system  contains,  when  carefully 
skimmed,  about  K)  percent,  fat.  This  and  all  other  creams  which  rise 
naturally  to  the  surface,  as  upon  bottled  milk,  owing  to  the  lesser  specific 
gravity  of  the  fat,  are  known  as  gravity  creams.  Cream  so  raised  under- 
goes no  change  of  its  fat  globules,  and  is  to-day  esteemed  by  many  author- 
ities as  superior  for  infant  feeding  to  the  centrifugal  cream  removed  from 
milk  by  the  mechanical  action  of  the  separator  macliines,  which  are 
thought  to  disturb  the  integrity  of  the  fat  globules,  making  them  more 
liable  to  coalesce.  Separator  cream  may  be  of  almost  any  density  and 
percentage,  depending  upon  the  s|)eed  and  number  of  revolutions  at 
which  the  machine  is  manipulated.  Cream  is  always  richer  in  l)acteria 
than  skimmed  milk,  since  these  are  mechanically  carried  along  with 
the  fat  globules.  Cream  as  sold  in  the  market  is  often  thickened  by  the 
addition  of  sul)stances  which  swell  up  the  mucoid  proteid,  and  so  make 
it  appear  richer  than  it  is.  It  is  often,  when  sold,  older  than  milk 
marketed  the  same  day.  A  not  uncommon  error  is  to  contaminate  a 
fairly  fresh  milk  with  an  old  bacteria-laden  cream.  It  is  much  better,  if 
it  is  desired  to  have  more  fat  than  proteids  in  any  modification  of  milk, 
to  use  the  upper  layers  of  a  milk  which  has  stood  a  sufficient  length  of 
time  to  have  the  fat  chiefly  in  the  upper  portion.  This  is  known  as 
"top  milk,"  and  will  ]ye  referred  to  as  such  hereafter.  The  advantage 
of  the  term  lies  in  the  fact  that  it  calls  attention  to  the  fact  that  we 
are  .simply  dealing  with  an  extra  fat  milk,  and  that  the  other  elements 
of  the  milk  are  still  there  in  nearly  the  same  proportions,  although 
actually  the  percentage  of  proteids  decreases  progressively  to  a  slight 
extent  as  the  percentage  of  fat  rises.  Since  the  stronger  top  milks 
are  necessarily  much  diluted  in  infant  feeding,  this  error  is  reduced ;  so 
that  for  practical  purposes  it  may  be  disregarded.  The  visible  cream 
layer  which  rises  upon  bottled  milk  does  not  var\'  ver\'  much  in  its 
height  and  amount,  but  is  much  denser — i.  e.,  contains  more  fat — in  a 
rich  than  a  poor  milk.  Moreover,  as  will  be  shown  later,  the  \-isible 
cream  in  any  bottle  is  not  of  the  same  richness  throughout,  the  action  of 
gravity  making  the  upper  portion  denser  than  the  lower;  so  that  if  dipped 
off  separately  the  top  ounce  would  contain  a  much  larger  percentage  of 
fat  than  the  lowest  ounce  of  the  cream  layer.  It  has  further  been  sho^\•n 
that  after  the  cream  has  risen  in  a  milk  bottle  which  is  usuallv  filled 
entirely  full,  ordinary  handling  in  transportation  does  not  disturb  the 
percentages  in  the  layers. 


CHAPTER    YIII. 

SUBSTITUTE  IXFAXT  FEEDIXG— FEEDING  AFTER  THE  FIRST  YE.IR. 

GENERAL  PRINCIPLES  INVOLVED  IN  SUBSTITUTE  FEEDING. 

Ix  the  evolution  of  modern  medicine  one  of  the  last  problems  to  be 
attacked  and  reduced  to  a  scientific  basis  has  been  that  of  substitute 
infant  feeding.  This  has  been  largely  due  to  the  fact  tliat  luider 
normal  conditions  the  human  infant  received  its  suitaljle  nourish- 
ment ready-made  from  the  maternal  breast,  and  owing  to  the  general 
cheapness  of  human  life  comparatively  httle  attention  was  paid  to  that 
small  proportion  of  infants  who  must  needs  fight  an  often  losing  fight  for 
existence  unless  they  could  be  nourished  by  a  foster-mother.  However 
the  startling  increase  in  the  number  of  mothers  who  from  physical  and 
social  causes  cannot  nurse  their  oft'spring,  together  with  a  tendency  to 
smaller  families,  has,  with  the  constantly  increasing  value  to  the  indi- 
vidual life,  aroused  a  wider  interest  in  the  subject. 

In  order  to  understand  the  principles  which  at  present  form  the  basis 
of  artificial  feeding,  it  is  well  to  be  familiar  with  the  various  theories  which 
have  been  held  at  different  times,  and  which,  proving  imperfect  or 
fallacious,  have  at  the  same  time  contributed  in  certain  ways  to  the  sum 
of  our  experience.  Many  have  been  retained  in  larger  or  smaller  part, 
but  modified  in  accordance  with  our  expanding  knowledge.  When  the 
milk  of  the  mother  failed,  some  substitute  was  necessary,  and  was 
chiefly  sought  by  analogy  in  the  milk  of  other  animals.  This  has  finally 
been  narrowed  down  to  that  of  the  cow.  But  fev^-  children  could  digest 
this  pure;  hence  dilution  was  practised.  Chemists  attempted  to  prepare 
foods  which  could  be  easily  digested,  but  unless  they  were  combined 
with  milk,  and  even  when  so  combined,  they  failed  in  the  main  to  produce 
perfect  nutrition.  Condensed  milk  obtained  wide  use,  but  its  low  fat 
and  proteids  and  high  sugar  content  produced  fat,  flabby  growth 
without  resistance  to  disease.  Some  knowledge  of  the  chemical  com- 
position of  breast  milk  then  led  to  attempts  to  imitate  its  average  pro- 
portions from  cows'  milk,  and  the  problem  seemed  solved,  but  it  did  not 
take  fully  into  consideration  the  inherent  differences  in  the  proteids  of 
the  two  milks,  and  peptonization  (pancreatization)  was  advanced  topre- 
digest  the  excess  of  casein.  Bacteriology  then  revealed  the  excessive  germ 
content  of  milk,  and  their  destruction  by  sterilization  was  advocated; 
but  this  gave  way  to  pasteurization,  and  more  recently  the  problem 
has  been  attacked  at  the  right  source  in  efforts  to  secure  clean,  fresh 
milk  of  low  bacterial  content  which  need  not  be  altered  by  cooking. 
Taking  more  accurate  analyses  of  breast  milk  for  the  basis,  success  was 

C  12.3  ) 


124  IN  FAX  r   FEEDING 

then  soufiht  by  propariiifj;  milk  wliicli  should  coiifonn  to  tlicso  analyses 
in  at  least  containini;'  the  proper  ])roj)()rtions  of  fat,  sii^ar,  and  proteids, 
and  hy  arranging  a  sehedide  of  inereas(>d  strengths  wliieii  sliould  advanee 
with  the  age  and  growth  of  the  child.  These  were  invariably  eoinbined 
with  the  nse  of  some  alkali  in  the  food,  whieh  we  now  know  has  a  definite 
effect  npon  the  digestive  processes.  Greater  success  was  attained  with 
normal  children  tiian  before, but  for  many  others  it  was  soon  found  neces- 
sary to  elaborate  a  plan  by  which  the  various  elemtMits  could  be  raised 
and  lowered  at  will,  'i'o  this  end  an  exact  knowledge  and  control  of  the 
contained  percentages  were  necessary,  which  led  to  the  establishment  of 
milk  laboratories  in  which  any  proportions  determined  npon  could  be 
produced,  'riiese  combinations  were  first  prepared  from  cream  and 
skimmed  milk  obtained  by  the  use  of  a  centrifugal  separator.  Then 
there  arose  an  objection  in  some  rjuarters  to  the  use  of  centrifugal  cream, 
and  this  and  the  necessity  for  adapting  the  method  to  prcjxiration  in  the 
home  led  to  a  wider  employment  of  the  richer,  n]>per  layers  pioduced 
upon  standing  by  the  action  of  gravity  in  bottled  milk.  The  chief 
difficulty  has  been  to  secure  in  every  case  the  proper  digestion  of  a 
sufficient  amount  of  the  peculiar  proteids  of  cows'  milk  to  maintain 
nutrition.  Cereal  gruels,  which  have  long  been  used  as  diluents,  and 
recently  have  been  more  commonly  dextrinized,  now  claim  a  new  ])lace 
in  that  they  are  said  to  mechanically  render  the  casein  coagulum  smaller 
and  thus  more  readily  digestible.  Egg-albumen  has  been  tried  to 
su])plement  deficient  proteids,  but  the  most  recent  move  of  importance, 
in  difficult  cases,  has  been  to  add  the  soluble  protcMils  of  Avhey,  called 
loosely  "whey  proteids,"  to  bring  the  ])rotei(l  content  up  to  the  needs 
of  the  child.  We  are  but  just  beginning  to  understand  that  as  the 
digestive  secretions  of  the  child's  stomach  make  their  appearance  their 
chemical  action  upon  the  milk  ingested  forms  with  it  coml)inations 
which  are  retained  and  acted  upon  longer  by  the  stomach  instead  of 
being  passed  on  into  the  intestines,  and  tliat  by  this  means  the  stomach 
fits  itself  in  time  for  the  digestion  of  solid  food,  but  the  larger  and 
tougher  curds  formed  from  cows'  milk  seriously  complicate  the  matter. 
Upon  the  further  elucidation  of  these  problems  of  digestion  lies  our 
greatest  hope  of  progress  in  the  future.  In  the  mean  time  the  o])inion 
has  been  reached  upon  all  sides  that  there  is  no  single,  royal  road  to 
successful  feeding  in  all  cases,  but  that  children  must  be  studied  as 
individuals  and  their  food  ada))ted  to  each,  not  only  with  a  competent 
knowledge  of  various  methods  and  of  the  indications  for  their  a])pli- 
cation,  but  also  with  a  view  not  alone  to  their  increase  of  weight,  but  to 
their  perfect  nutrition. 

Food  Elements  and  their  Purposes  in  Nutrition. — The  necessary 
elements  of  food  to  maintain  life  and  to  ])rovide  for  growth  and  repair 
are  fat,  proteids,  carbohydrates,  mineral  salts,  and  wat(M-,  and  the  pro- 
portions of  these  required  depend  u])on  the  species  and  the  type  of 
the  digestive  organs.  The  adult  re(juires  these  largely  for  the  pro- 
duction of  heat  and  energy  and  to  replace  tissue  waste.  The  young 
demand   them   in   addition   for  tissue   building  in   their  more  or   less 


SUBSTITUTE  IXFAXT  FEEDIXG  125 

rapid  growtl:.  Eacli  element  plays  its  own  distinctive  part  in  the 
economy. 

Fats  and  carbohydrates  containing  hydrogen,  carbon,  and  oxygen  are 
producers  of  heat  and  energy*,  which  may  also  be  stored  up  potentially 
in  the  body  as  fat.  Proteids,  which  contain  in  addition  to  hydrogen, 
carbon,  and  ox^-gen  also  nitrogen,  sulphur,  and  phosphorus,  are  the  only 
true  tissue  builders. 

Fat. — Fat  not  only  appears  as  such  in  the  body,  but  is  necessaiy  for 
proper  building  of  the  nervous  and  osseous  systems.  As  a  fuel  for  the 
maintenance  of  bodv  heat  it  has  two  and  one-fourth  times  the  value 
of  sugar  or  proteid,  and  one  of  its  important  function-  i-  to  spare  the 
proteid  from  being  dra'ttm  upon  for  heat  production.  Breast  milk 
contains  from  3  to  5  per  cent,  of  fat,  and  we  endeavor  during  the  first 
three  months  to  give  as  near  3  per  cent,  as  possible  in  the  food,  not 
alone  for  the  immediate  needs  of  the  body,  l)ut  because  a  larger  percentage 
of  fat  than  proteid  favors  mechanically  by  its  presence  the  digestion  of 
the  proteids,  while  the  residue  of  unabsorbed  fat  serves  to  maintain  a 
soft  consistency  of  the  feces,  preventing  constipation. 

Proteids. — From  the  foregoing  the  immense  importance  of  proteids  in 
the  food  is  self-evident,  for  T^dthout  their  absorption  in  suitable  amounts 
there  can  be  no  proper  gro^"th  and  development,  and  we  can  readily 
understand  that,  since  the  young  infant  must  begin,  on  account  of  it- 
more  difficult  digestibility,  with  proteid  percentages  of  cows'  milk  much 
below  that  of  the  1.50  per  cent,  contained  in  breast  milk,  the  bottle-fed 
child  is  necessarily  handicapped  from  the  start  until  it  can  digest  an 
amount  of  proteids  equal  to  that  of  breast  milk,  which  is  rarely  the  case 
before  the  fifth  to  sixth  month.  Proteids  are  also  blood  builders,  and 
prolonged  deficiency  of  proteids  in  the  food  produces  anemia  as  well 
as  malnutrition.  Proteids  can  be  called  upon  to  produce  body  heat, 
but  such  a  necessity  is  disastrous  and  should  be  prevented  hv  furnishing 
ample  fat  and  carbohydrates  in  the  food. 

Carbohydrates. — Carbohydrates,  which  include  sugars  and  starches, 
play  a  most  necessary  role.  They  can  be  and  are  converted  in  the  body 
into  fat,  and  are  an  important  source  of  animal  heat,  but,  hke  fat,  they 
cannot  restore  nitrogenous  waste  nor  build  new  cell-. 

Mineral  Salts. — Mineral  salts  not  only  are  necessary  for  the  formation 
of  bone  but  of  other  tissues,  and  for  the  secretions  of  organs  wliich  carry 
on  the  ftmctions  of  the  body. 

Water. — This  enters  largely  into  tlie  composition  of  the  body,  even 
the  bones  containing  10  per  cent.,  but  is  also  required  to  maintain  its 
fluids  and  the  functions  of  digestion,  secretion,  and  excretion.  The 
major  part  must  be  introduced  as  such  with  the  food.  A  smaller  pro- 
portion is  released  by  digestion  from  mechanical  or  chemical  combination 
with  the  food. 

All  experiments  in  nutrition  have  resulted  practically  in  the  same 
conclusion  that  each  animal  must  have  a  well-balanced  ration  suited 
to  its  special  needs.  All  deviations  from  the  normal,  if  persisted  in, 
are  eventtiallv  productive  of  harm.     The  modern  feeding  of  infants  is 


12(i 


IXFA.XT  FEEDING 


based  iij)()n  the  j)rinciple  that  breast  milk  is  the  ideal  food  for  them, 
and  that  any  siil)stitute  food,  to  be  siieeessful,  must  resemble  it  closely, 
not  only  by  furnishing  the  same  elements,  but  the  same  elements  in  as 
nearly  as  possible  the  same  form,  and  also  by  maintaining  a  similar 
balance  in  their  proportions  and  producing  normal  development  of  the 
digestive  organs.  Cows'  milk,  when  properly  modified  in  the  {propor- 
tions of  its  elements,  is  the  only  generally  available  substitute  which  can 
fulfil  these  conditions  with  reasonable  approximation,  since  no  manu- 
factured food  has  ever  been  devised  which  does  this.  Nevertheless, 
when  approaching  the  subject  of  tlie  modification  of  cows'  milk  we  must 
start  with  the  definite  understanding  that  while  all  milks  resemble  each 
other  in  gross  appearances,  human  milk  and  cows'  milk  are  in  certain 
other  respects  two  very  different  fluids  designed  by  nature  to  meet  the 
needs  of  the  young  of  two  diiTerent  species  with  different  re(juirements 
and  different  types  of  digestive  aj^paratus.  These  differences  are  best 
shown  in  the  following  tal)le,  freely  atlapted  from  Rotch: 

Table  Compakjng  Woman's  Milk  and  Cows'  Milk. 


NUTRITIVE   DIFFERENCES. 


Reaction. 

Water. 

Mineral  matters. 
Total  solids. 
Fats. 

Lecithin. 

Sugar. 

Proteids  (total). 

Casein. 

Soluble  proteids. 


Coagulation  of  casein 
by  acids. 


Coagulation  of  casein 

by  rennet. 
Action  of  gastric  juice  ; 

rennet  plus  acid,  plus 

pepsin. 


Woman's  milk  directly  from 
the  breast. 

Faintly  acid  to  phenolphthal- 

ein. 
85.00  to  90.00  per  cent. 

0.18  to   0.25 
15.a)  to  10.00 

3.00  to    5.00 

(relatively  poor  in  fatty  acids), 
larger  amount. 
6.00  to  7.00  per  cent. 
1.00  to  2.25 


Cows'  milk  as  ordinarily  received 
(about  twenty-four  hours  old). 

Slightly  acid  to  pheuoiplithalein. 


85.00  to  88.00  per  cent. 

0.70  to   0.75 
15.00  to  12.00 

3.00  to  5.00 

(relatively  rich  in  fatly  acids), 
smaller  amount. 
4.00  to  5.00  per  cent. 
3.00  to  4.00 
2.00  to  3.00 
0.0(i  to  0.85       " 


PHYSIOLOGICAL    DIFFERENCES. 


Curds  with   difficulty  in  line 
flocculi. 


In  loose  flocculi. 


Curds  easily  with  small  amounts  of 
acids  in  finely  divided  curds.  With 
larger  amount  of  acid  in  larger  and 
more  tenacious  curds. 

Solid  mass. 


Flocculent  precipitate,  readily 
digested. 


Jlore  or  less  tough  curds  of  various 

sizes  with   tendency  to  shrink.    Di 

gestibility  varies  with  size  of  curd 

and  niiantity  of  gastric  secretion. 

Note.— The  methods  of  separating  thccaseiu  and  soluble  proteids  of  cows'  milk  are  not  applicable 

to  human  milk  because  the  caseins  behave  diflerentiy  with  reagents.    No  analysis  thus  far  made 

can  be  accepted  without  question 

Comparison  of  the  above  table  not  only  shows  that  while  the  percentage 
amounts  of  the  fat  are  the  same,  tho.se  of  tlie  sugar,  proteids,  and  mineral 
matter  are  (juite  different.  But  it  is  still  more  nece.s.sary  that  we  should 
understand  that  there  are  very  vital  differences  in  the  composition  in 
some  of  these  groups.  The  most  noticeable  difference  is  in  the  proteids. 
In  cows'  milk  there  is  a  marked  preponderance  of  casein  over  soluble 
proteids.     In  breast  milk,  according  to  the  best  recent  analyses,  the 


SUBSTITUTE  INFANT  FEEDING  127 

soluble  proteids  exceed  the  casein,  although  not  as  largely  as  was 
formerly  supposed.  The  difficulty  in  separating  these  bodies  is  greater 
than  in  cows'  milk,  and  there  is  some  doubt  whether  it  has  as  yet  been 
satisfactorily  accomplished.  The  marked  contrast  between  the  behavior 
of  the  caseins  of  the  two  milks  wnth  acid  and  rennet  during  digestion, 
which  causes  the  chief  difficulty  when  cows'  milk  is  fed  to  the  infant,  is 
not  accounted  for  by  the  differences  in  the  quantities,  since  it  is  not 
materially  altered  by  dilution  of  cows'  milk,  and  points  strongly  to 
inherent  chemical  differences.  In  the  mineral  ash  of  cows'  milk,  which 
is  more  than  three  times  that  of  breast  milk,  there  is  more  lime,  mag- 
nesium, potassium,  and  phosphoric  acid,  and  less  chlorine  and  sulphur. 
The  lecithin  in  breast  milk,  which  enters  into  the  formation  of  the 
nervous  system,  considerably  exceeds  that  in  cows'  milk. 

Even  the  fats,  although  largely  the  same,  differ  because  of  the  presence 
in  cows'  milk  of  large  amounts  of  volatile  fatty  acids.  When  these  differ- 
ences in  composition  and  digestibility  are  considered,  together  with  the 
probability  that  breast  milk  contains  properties  which  nature  designed 
especially  for  the  requirements  of  the  human  infant,  we  will  see  that  no 
amount  of  dilution  or  modification  will  produce  an  exact  counterpart 
of  breast  milk;  therefore,  the  infant  so  fed  must  have  its  digestive  tract 
trained  to  utilize  a  different  kind  of  food  from  that  which  nature  intended. 
We  recognize  from  the  foregoing  table  that  6  to  7  per  cent,  of  milk- 
sugar  in  breast  milk  can  be  utilized  by  the  infant,  that  the  fat  as 
supplied  by  the  mother  exceeds  the  amount  of  proteid,  and  that  the 
ability  to  digest  a  certain  percentage  of  proteid  (1.5  to  2  per  cent.)  should 
be  attained  as  soon  as  practicable,  and  that  these  elements  should  be 
sufficiently  diluted  with  water.  Beyond  this  we  are  not  able  to  go. 
The  salts,  the  enzymes,  the  protective  principles,  and  other  properties 
which  we  can  only  surmise  that  breast  milk  contains,  we  as  yet  make 
no  attempt  to  imitate.  Yet,  despite  the  radical  differences  between  the 
two  milks,  much  more  successful  feeding  than  w^as  formerly  attained 
has  been  accomplished  by  modifying  the  relative  proportions  of  the 
elements  of  cows'  milk,  taking  as  a  general  guide  to  the  requirements 
of  the  infant  the  composition  and  percentages  of  breast  milk.  Where 
failure  has  occurred  it  has  been  largely  due  to  adhering  to  these  too 
closely  in  all  cases,  and  losing  sight  of  the  still  irremediable  differences 
in  digestibility. 

Modified  Milk. — Modified  milk  is  primarily  any  milk  which  has 
undergone  any  change  in  the  amounts  or  relations  of  its  constituent 
parts,  so  that  the  old-time  physician  who  fed  infants  on  diluted  and 
sweetened  cows'  milk  used  a  modified  milk.  As  the  term  is  now  used, 
it  is  ordinarily  applied  to  cows'  milk  prepared  for  infants  by  decreasing 
or  increasing  any  of  its  constituent  parts,  or  the  addition  of  other  sub- 
stances which,  of  course,  includes  its  dilution  with  water.  This  is  now 
based  upon  a  clearer  knowledge  of  the  probable  requirements  of  the 
infant,  which  has  come  from  a  study  of  the  analyses  of  breast  milk. 
From  this  we'  learn  that  cows'  milk  contains  from  two  to  three  times  as 
much  proteid  as  breast  milk;  therefore,  we  dilute  the  cows'  milk,  and. 


128  IMAXT   FEEDIXG 

since  this  also  reduces  the  amount  of  fat  and  sugar,  avc  employ  measures 
to  increase  these  to  the  recjuisite  amount. 

Percentage  Feeding. — Percentage  feeding,  so  called,  is  but  a  further 
step,  and  simply  consists  in  making  our  modifications  of  cows'  milk  in 
such  a  way  that  we  know  approximately  the  amount  of  fat,  sugar,  and 
proteid  in  the  food,  when  it  is  prepared,  as  an  intelligent  guide  first  to 
its  selection  for  any  particular  case,  and  secondly,  what  is,  if  anything, 
more  important,  as  a  guide  to  any  subsecjuent  changes  which  may  be 
found  necessary.  We  are  then  not  working,  as  of  old,  in  a  hap-hazard 
manner  and  in  the  dark,  but  upon  definite  known  lines,  with  a  rational 
scientific  basis.  The  common  error  of  seriously  disturbing  an  infant's 
digestion  by  jumping  from  a  nnicli  diluted  condensed  milk  containing 
a  small  percentage  of  proteids  to  diluted  cows'  milk  with  a  high  proteid 
percentage  will  not  be  made  by  one  who  has  studied  the  subject  enough 
to  know  the  differences  and  to  form  a  rough  working  estimate  of  percent- 
ages. Every  practitioner  should  at  least  understand  the  meaning  of  the 
values  which  they  represent.  The  ability  to  think  in  percentages  so  that 
any  given  dilution  of  cows'  milk,  or  of  a  cream  of  known  strength,  with 
any  given  number  of  parts  of  water  at  once  suggests  the  approximate 
percentages  of  fat  and  proteid  can  be  readily  acquired  by  some  study 
and  by  practice.     It  gives  to  the  subject  a  hitherto  unknown  interest. 

Calculating  Percentages. — Although  we  have  seen  that  average  cows' 
milk  contains  4  per  cent,  fat,  5  per  cent,  sugar,  and  3.50  per  cent,  proteids, 
since  the  fat  and  proteids  vary  in  different  milks,  we  may  assume  for 
practical  purposes  of  calculation  that  these  are  4  per  cent,  fat,  4  per  cent. 
sugar,  antl  4  per  cent,  proteids,  and  one  who  desires  to  accjuire  the  habit 
of  rapidly  estimating  percentages  will  do  well  to  work  at  first  upon  this 
basis.  If  it  is  desired,  upon  the  one  hand,  to  dilute  one  part  of  milk  with 
1,  2,  3  or  more  parts  of  the  diluent  (water,  barley-water,  etc.,  as  the  case 
may  be)  the  resulting  amount  of  fat,  sugar,  and  proteids  will  be  found 
by  dividing  the  constant  number  4  by  the  total  number  of  parts  of  milk 
and  diluent  added  together.  Thus,  in  1  part  milk  and  1  ])art  water 
divide  the  4  per  cent,  each  of  fat,  sugar,  and  ])rotcids  by  the  total  number 
of  parts,  which  is  2,  and  gives  2  per  cent,  each  of  fat,  sugar,  and  proteids 
in  the  mixture;  1  part  of  milk  and  2  of  water  divide  4  by  3  and  give 
1.33  per  cent,  each  of  fat,  sugar,  and  proteids;  1  part  milk  and  7  parts 
water  divide  4  by  S  and  give  0.50  per  cent,  each  of  fat,  sugar,  and 
proteids.  The  sugar,  hov/ever,  is  easily  adjusted  later,  so  that  we  require 
only  to  determine  the  amount  of  fat  and  proteids. 

On  the  other  hand,  if  we  desire  to  ])re])are  a  mixture  for  the  infant 
which  contains  only  0.50  per  cent,  of  fat  and  proteids  and  wish  to  know 
how  many  parts  of  Avater  are  rec(uired,  we  divide  the  4  per  cent,  of  fat 
and  proteids  in  1  part  of  milk  l)y  0.50  and  find  that  it  goes  eight  times — 
i.  e.,  the  mixture  will  be  one-eighth  the  strength  of  plain  milk  giving 
the  fraction  \.  Our  mixture  then  would  consist  of  8  parts — that  is, 
1  part  milk  diluted  with  7  parts  water.  Again,  if  we  wish  a  mixture 
containing  1.00  per  cent,  each  of  fat  and  proteids  we  divide  4  by  1, 
which  gives  us  4  parts  for  our  mixture  or   the  fraction  |,  wdiich  will 


SUBSTITUTE  IXFAXT  FEEDING  129 

be  1  part  milk  and  3  parts  diluent.  The  most  common  error  is  to 
consider  only  the  parts  of  the  diluent  and  neglect  the  parts  of  milk. 
With  this  one  exception  the  matter  is  very  simple. 

Slightly  more  difficult  to  grasp  is  where  more  than  1  part  of  milk  is 
used.  For  example,  2  parts  of  milk  and  1  part  of  water.  Here,  as 
before,  we  divide  by  the  total  number  of  parts,  or  3;  but  since  each 
part  of  milk  used  contains  4  per  cent,  each  of  fat  and  proteids,  2  parts 
contain  8  per  cent,  of  each,  and  this  8  per  cent,  divided  by  3  gives  us 
2.66  per  cent,  in  our  mixture.  Reversing  this  process  and  desiring  to 
form  a  mixture  containing  2.66  per  cent,  each  of  fat  and  proteids — that 
is,  containing  two-thirds  of  the  amount  of  fat  and  proteids  in  plain  milk 
(4  per  cent.) — we  make  a  mixture  of  3  parts,  2  of  which  will  be  milk 
and  the  remaining  1  part  of  water. 

Were  it  1.60  per  cent,  of  fat  and  proteids  which  were  desired,  or  two- 
fifths  of  the  fat  and  proteids  in  plain  milk,  we  would  require  a  total  of 
5  parts,  of  which  2  parts  are  milk  and  the  3  remaining  parts  water.  In 
short,  the  fraction  shows  what  proportion  of  the  feeding  mixture  must 
be  milk,  whether  it  be  of  one  feeding  or  of  a  supply  sufficient  for  the 
entire  day.  For  a  single  bottle  to  contain  1.60  per  cent,  fat  and  proteids, 
which  would  require  two-fifths  milk,  we  may  use  2  ounces  of  milk  and 
.the  remaining  three-fifths  or  3  ounces  diluent.  The  same  quantities 
may  be  multiplied  by  the  number  of  feedings  for  the  day;  or,  if  each 
bottle  is  to  contain  more  or  less  than  5  ounces,  we  may  make  up  10,  20, 
30,  or  40  ounces,  of  which  two-fifths  are  milk  and  the  remaining  three- 
fifths  diluent,  place  the  exact  amount  desired  in  each  bottle,  and  reject 
any  excess. 

As  familiarity  with  this  process  develops,  one  comes  to  associate  the 
percentages  most  commonly  employed  with  the  fraction  which  represents 
their  relation  to  plain  milk.  One-half  hour  spent  with  pencil  and  paper 
in  verifying  each  step  in  the  above  figures  and  those  in  the  following 
table  will  prove  more  useful  in  mastering  the  principles  than  many 
rereadings  of  the  text. 

Table  Showing  the  Number  op  Parts  of  Cows'  Milk  and  Diluent  Required 
TO  Secure  Certain  Desired  Percentages  of  Fat  and  Proteids. 


.  Per  cent. 

Fraction  repre- 

of fat  and 

senting  amount 

Total 

proteids 

of  milk  in 

parts. 

required. 

mixture. 

0.25 

= 

Vl6 

— 

16 

0.33 

= 

Vl2 

= 

12 

0.50 

= 

Vs 

= 

8 

0.57 

= 

1/7 

= 

7 

0.67 

= 

\ 

= 

6 

0.80 

=  ' 

"5 

= 

5 

1.00 

= 

1/4 

= 

4 

1.18 

= 

'h 

= 

7 

1.33 

= 

Hs 

= 

3 

L60 

= 

2/5 

= 

5 

2.00 

= 

1/2 

= 

2 

2.50 

= 

'Is 

= 

8 

2.66 

= 

% 

= 

3 

3.00 

== 

^li 

= 

4 

less 


Parts  milk 

Parts  diluent 

required. 

required. 

1 

leaves               15 

1 

"                   11 

1 

7 

1 

6 

1 

5 

1 

4 

1 

3 

2 

5 

1 

2 

2 

3 

1 

1 

5 

3 

2 

1 

3 

I 

130  INFANT  FEEDING 

Our  priinary  purpose  in  diluting  cows'  milk  is  to  reduce  the  excessive 
amount  of  proteids,  not,  as  used  to  be  taught,  to  make  it  correspond  to 
that  of  an  average  breast  milk,  but  to  a  point  where  the  dissimilar  pro- 
teids will  be  readily  digested  by  the  infant.  By  such  dilutions,  carried 
as  far  as  may  be  deemed  advisable,  the  percentage  of  proteids  in  cows' 
milk  may  l)e  reduced  to  any  point  determined  upon  as  suitable  for  the 
individual  infant,  decided  by  its  digestive  ability,  but  in  so  doing  the 
percentages  of  fat  and  sugar  will  also  be  lowered.  How,  then,  may  the 
fat  and  sugar  be  rais(>d  or  secunMJ  in  tlic  mixture  in  suitable  amounts? 

To  Secure  the  Required  Proportion  of  Fat  in  Modified  Milk. — Experience 
has  shown  us  that  older  methods,  which  call  for  the  adding  of  cream  to 
milk  to  raise  the  amount  of  fat  in  the  mixture,  are  not  only  exceedingly 
inaccurate  in  their  results,  owing  to  great  variations  in  the  strength  of 
so-called  "cream,"  but  also  refpiire  too  (•omj)licated  calculation  on  the 
part  of  the  physician,  beside  increasing  the  dangers  arising  from  previous 
manipulations  of  the  ingredients.  (See  page  122.)  The  system,  therefore, 
which  bids  fair  to  supplant  all  others  is  that  of  the  use  of  "top  milks"  of 
various  strengths,  to  furnish  the  different  percentages  of  fat  which  we 
may  recjuire.  Fortunately,  also,  tiiis  system  is  e(|ually  applicable  to 
cities  and  large  towns,  where  milk  bottled  at  the  farm  should  alwaj's  be 
obtainable,  and  to  the  country,  where  it  may  be  placed  in  quart  preserving 
jars  soon  after  milking.  Careful  analyses  have  been  made  of  each 
successive  ounce  removed  from  the  top  downward  from  the  ordinary 
cjuart  milk  bottle,  and  have  shown  that  after  standing  until  the  cream 
has  risen  the  top  ounce  is  richest  in  fat  and  the  lowest  the  poorest  in 
fat  for  the  upper  ten  ounces,  with  a  progressive  decrease  from  the  first 
to  the  tenth.  This  shows  that  not  only  has  the  visible  cream  layer, 
which  amounts  on  the  average  to  between  5  and  0  ounces,  a  different 
density  in  each  successive  layer,  but  that  the  same  is  true  of  the  upper 
•part  of  the  milk  upon  which  the  cream  has  risen.  This  will  be  shown  by 
the  first  column  of  the  table  on  page  131,  taken  from  Chapin  (Fig.  29). 

Below  the  tenth  ounce  the  skimmed  milk  is  assumed  for  practical 
purposes  to  have  about  the  same  fat  content.  By  inspection  of  the 
second  column  of  figures,  in  the  same  table,  it  will  be  readily  seen  tliat 
when  2,  3,  or  more  ounces  are  removed  from  such  a  bottle,  and  mixed, 
each  additional  ounce  reduces  the  percentage  of  fat  in  the  mixture,  since 
it  is  progressively  diluted  by  those  containing  less  and  less  fat.  To  avoid 
misunderstanding  it  must  be  stated  at  this  point  that  the  amount  of  fat 
contained  in  any  given  numl)er  of  ounc(>s  of  top  milk  is  not  the  same 
with  poor,  average,  and  rich  milk,  although  the  ratio  of  fat  to  proteids 
remains  about  the  same.  Therefore,  if  the  milk  is  very  rich,  5  per  cent, 
fat,  or  very  poor,  3  per  cent,  fat,  about  2  ounces  more  and  2  ounces  less, 
respectively,  should  be  taken  to  get  suitable  percentages  of  fat.  A  good 
average  milk  which  contains  about  4  per  cent,  fat  is  preferable  for 
infant  feeding. 

Accuracy  in  removing  the  requisite  number  of  ounces  is  essential  to 
the  finer  application  of  these  principles.  Pouring  off  the  upper  jx^rtion 
which  is  to  be  used  into  a  graduated   measure,  or  siphoning  away  the 


SUBSTITUTE  IXFAXT  FEEDING 


131 


lower  part  which  is  to  be  rejected,  are  crude  methods  which  do  not 
permit  of  great  accuracy,  ahhough  pemiissible  when  other  means  are 
not  available.  Various  flat,  pointed,  and  round-bottomed  dippers  have 
been  devised  for  this  purpose,  each  of  which  contains  1  ounce,  and  at  the 
same  time  serv^es  to  remove  the  upper  layers  without  undue  disturbance 
and  also  to  measure  the  quantity.  A  milk  bottle  properly  prepared  for 
shipping  is  completely  full.    The  first  ounce  or  dipperful  must  therefore 


ONE  QUART  MILK 

4.1%  FAT 

WITH  CREAM  RISEN 


LAYER  OF  CREAM 

NOT  UNIFORM  IN 
COMPOSITION 


Fig. 29 
LAYERS  OF  CREAM   NOT  UNIFORM 
IN  COMPOSITION. 


FAT  IN  EACH  OUNCE. 


2M0Z. 


JglOZ.  CONTAINS  25f^  FAT 


23  fc 


35502. 


4iyoz. 


5iyoz. 


StMOZ. 


28IH0Z. 


32ND02. 


FAT  IN  DIFFERENT  PORTIONS 

REMOVED  FROM  THE  TOP 

AND  MIXED. 


TOP    2  OZS.  MIXED  24^  FAT 


19^     " 

"      3  OZS.      " 

22.5^" 

18.5:?  " 

"       4  OZS.      •' 

21. 4;^.  " 

10.5^  " 

"       5  OZS.      " 

19.2;^" 

4.81  " 

"      6  OZS.      " 

16.8,1" 

3.41  " 
2.21  '• 
1.8,1  " 
1.21  " 

"      7  OZS.      " 
"      8  OZS.      " 
"       9  OZS.      " 
"     10  OZS.      " 

15.0;^" 
13.31  " 
11.5;^  " 

1.2;1    " 

"     12  OZS.      " 

9.0,1  " 

1.21   " 

"     14  OZS.      " 

7.8;^" 

1.2,1   " 

"     16  OZS.      " 

7.0^" 

1.21    " 

"     13  OZS.      " 

6.3,1" 

1.2,1    " 

"    20  OZS.      " 

5.8,1" 

1.2;?  " 

"    22  OZS.      " 

5.41" 

1.2;;.    " 

"    24  OZS.      " 

5.0,1  " 

\.Zfc     " 

"    26  OZS.      " 

4.7,1  " 

1.21    " 

"    28  OZS.      " 

4.51'  " 

1.2,1    " 

"    30  OZS.      " 

4.3,1  " 

1.2,1    " 

ALL  MIXED 

4.1;^  " 

Distribution  of  fat  in  bottled  milk  after  cream  has  risen.    (Chapin.) 

be  removed  with  a  teaspoon,  after  which  the  other  dipperfuls  are  secured 
by  just  submerging  the  upper  edge  of  the  dipper,  which  skims  off  the 
successive  layers  (Fig.  30).  Such  dippers  are  of  great  value  in  im- 
pressing upon  the  mother  the  importance  of  exact  proportions  in  the 
infant's  food,  and  may  be  used  by  her  also  for  measuring  the  diluent.^ 
By  this   simple   means  of   removing  and   mixing  different  numbers  of 


1  A  good  tinned  dipper  may  be  had  by  mail  for  ten  cents  from  the  Cereo  Company,  Tappan,  N.  Y., 
or  an  aluminum  one  for  twenty  cents  from  J.  Dougherty,  409  W.  59th  Street,  New  York  City. 


132 


I.XFAXT  FEEDING 


Fig. 30 


ounces  \vc  may  tluMi  easily  secure  a  top  milk  containing  almost  any 
(lesir(>(l  j)erceuta^e  of  extra-fat  milk.  Now,  for  all  practical  purposes, 
the  presence  of  extra  fat  does  not  displace  a  very  appreciable  amount  of 
protcids;  so  that  we  may  consider  that  the  percentage  of  proteids  in  any 
given  number  of  ounces  removed  and  mixed,  remains 
the  same  as  that  of  plain  milk,  which  we  know  to  be 
3.50  per  cent,  to  4  per  cent.,  and  we  can  also  secure, 
by  removing  and  mixing  a  given  number  of  ounces, 
any  desired  ratio  between  the  fat  and  proteids.  This 
may  be  10  per  cent.,  12  per  cent,,  10  per  cent.,  8  per 
cent.,  or  (5  per  cent,  fat  in  the  top  milk,  and  conse~ 
ciuently4,  3,  21,  2  or  1 1  times  as  much  fat  as  proteids, 
while  by  shaking  the  whole  bottle  so  as  to  redis- 
tribute the  cream  evenly  we  again  secure  plain  milk 
in  which  the  fat  and  proteids  are  equal  or  both  about 
4  per  cent.  To  reduce  this  principle  to  a  simple 
working  basis  it  is  only  necessary  for  the  practitioner 
to  remember  the  following  figures  for  good  average 
milk,  containing  about  4  per  cent,  fat :  Top  9  ounces 
(upper  third)  gives  12  per  cent,  fat,  or  fat  three  times 
the  proteids.  Top  15  ounces  (upper  half)  gives  <S  per 
cent,  fat,  or  fat  twice  the  protcids.  Plain  milk  (whole 
bottle)  gives  4  per  cent,  fat,  or  fat  ecjual  the  proteids. 
For  very  rich  milk  (5  per  cent.)  take  2  ounces  more  top 
milk,  and  for  very  poor  milk  take  2  ounces  less. 

This  certainly  requires  no  great  effort  of  memory. 
The  diagram  on  page  133  will  show  this  in  another  way. 
These  three  furnish  the  basis  for  the  usual  modifi- 
cations required  in  the  ordinary  infant  feeding,  and 
the  physician  who  employs  these  understandingly  for  a  time  soon  finds 
himself  forming  intelligently  other  combinations  of  fat  and  proteids,  by 
removing  progressively  a  larger  or  smaller  number  of  ounces  from  the 
top  of  the  bottle,  as  he  wishes  to  decrease  or  increase  the  proportion  of 
fat  to  the  proteids,  since,  as  may  be  seen  by  reference  to  Fig.  20,  taking 
oft'  less  ounc(\s  gives  a  top  milk  richer  in  fat,  and  taking  oft'  more  ounces 
one  containing  less  fat. 

The  same  rules  are  applied  to  the  finding  of  fat  percentages  for  "top 
milks"  that  we  have  outlined   for  plain  milk  (page  128).    Thus,  with 

1  part  12  per  cent,  fat  top  milk  (top  9  ounces)  and  3  ]>arts  of  diluent 
we  divide  the  12  per  cent,  fat  and  4  per  cent,  proteids  by  4,  the  total 
parts  used,  which  gives  us  3  per  cent,  fat  and  1  per  cent,  proteids  in  the 
mixture.    Again,  with  1  part  8  per  cent,  fat  top  milk  (top  15  ounces)  and 

2  parts  of  diluent  we  divide  8  per  cent,  fat  and  4  per  cent,  proteids  by 
3,  the  total  parts,  and  find  2.60  per  cent,  fat  and  1.33  per  cent,  proteids 
in  the  mixture.  Having  learned  from  practice  what  the  resulting 
percentage  of  the  proteids  will  be  if  the  milk  is  one-half,  one-third,  or 
one-fourth,  etc.,  of  the  mixture,  and  knowing  that  the  fat  percentage  will 
remain  equal  to  or  twice  or  three  times  the  proteid  percentage,  whatever 


Chapin  dipper  for  re- 
moving tup  milk;  liolds 
exactly  one  oimcc. 


SUBSTITUTE  IXFAXT  FEEDIXG 


133 


the  dilution,  according  to  the  strength  of  the  top  milk,  or  milk  we  are 
using,  the  calculation  is  rapidly  made  in  one's  head;  then  percentage 
feeding  loses  its  terrors,  and  we  estimate  percentages  as  easily  as  we 
would  the  number  of  grains  to  the  teaspoonful  in  a  4-ounce  mixture. 

To  Secure  Suitable  Percentages  of  Sugar  in  Modified  Milk. — Breast  milk 
contains  6  to  7  per  cent,  of  milk-sugar,  lactose,  which  varies  little  in 
amount  throughout  lactation.  This  indicates  to  us  that  the  infant  can 
absorb  and  utilize  this  heat  and  fat-producing  element  of  its  food  in 
considerable  amount.  Cows'  milk  contains  actually  about  5  per  cent. 
lactose,  which  is  naturally  still  further  reduced  by  dilution  of  the  milk. 
Since  we  take  breast  milk  so  far  as  possible  as  our  model,  this  deficiency 
must  be  made  up  in  the  infant's  food,  because  not  only  is  it  absorbed 


Fig. 


Upper  third.  Kiiie  ounces  top 
milk.  Fat  percentage  three 
times  that  of  original  milk. 
Proteid  percentage  same  as 
original  milk.  Fat  three  times 
the  proteids. 


Upper  half.  Fifteen  ounces 
top  milk.  Fat  percentage 
twice  that  of  original  milk, 
Proteid  percentage  same  as  orig- 
inal milk.  Fat  twice  the  pro- 
teids. 


Contents     of    entire    bottle 
mixed.    Plain  milk.    Fat  same 

as  proteids. 


with  less  trouble  than  the  other  elements  of  the  food,  but  because  its 
consumption  in  the  body,  like  that  of  the  fat,  prevents  the  proteids  from 
being  called  upon  to  produce  heat  when  they  should  be  utilized  for  tissue 
building.  :Miik-sugar  is  preferred  by  those  who  adhere  closely  to  breast 
milk  as\  model,  but  cane-sugar  may  often  replace  milk-sugar  with  good 
results  when  employed  in  rather  less  quantity,  since  it  is  both  sweeter 
and  more  liable  to  fermentation  during  digestion.  The  malt-sugars 
which  enter  largely  into  some  infant  foods  are  readily  absorbed  and  are 
more  laxative  in  their  effect.  In  modifying  milk  we  no  longer  consider 
it  imperative  to  calculate  the  percentage  of  sugar  resulting  from  the 
necessarv  dilution,  since,  for  practical  purposes,  the  addition  of  a  suitable 
quantity  of  sugar  can  be  accomplished  by  rule  of  thumb.  Two  and 
a  half  fairlv   level  tablespoonfuls  of  milk-sugar  and  two  exactly  level 


134  IXr.WT   FEEDISG 

tablespoonfuls  of  fjianulated  cane-suj^ar  equal  1  ounce.  If  1  ounce  of 
sui'ar  is  added  to  each  20  ounces  of  milk  durinfj  modification  we  shall 
have,  with  whatever  su<rar  is  alreadyin  the  diluted  milk,  about  b\  percent, 
for  the  weaker  formula'  and  i\\  jier  cent,  for  the  stronger  formulte,  which 
will  be  about  right  for  our  purposes. 

In  making  smaller  cpiantities  of  food,  one  fairly  level  tablespoonful 
of  milk-sugar  and  one  hca|)ing  teaspoonful  of  cane-sugar  to  8  ounces 
furnish  the  same  j)r()])()rti()ns.  When  dextrinizcd  gruels  are  used  as 
a  diluent  the  change  in  them  of  the  starch  to  dextrose  and  maltose  calls 
for  making  the  above  mea-sures  scant  or  the  total  percentages  of  sugar 
will  be  too  high.  Also,  when  the  milk  in  the  mixture  exceeds  one-half 
of  the  whole  the  sugar  should  be  gradually  reduced  to  three-fourths 
and  later  to  one-half  the  ai)ove  ((uantities,  especially  with  the  use  of 
gruel  diluents.     When  plain  milk  is  reached  no  sugar  need  be  added. 

Diluents. — ^Starting  witii  the  jjremise  that  the  proteids  of  cows'  milk, 
as  has  been  shown,  are  different  from  those  of  breast  milk,  both  in 
amoimt  and  in  the  prej)on(lerance  of  the  curd-forming  casein,  and  that 
this  casein  of  cows'  milk  tends  to  coatjulate  in  the  stomach  in  large  and 
tough  ina.sses,  instead  of  small,  soft  flocculi,  various  methods  of  pre- 
paring the  milk  have  i)een  adopted,  at  first  quite  empirically,  to  over- 
come this  serious  difficulty,  and  each  ha.s  proven  reasonably  successful 
in  the  hands  of  the  originators  and  their  group  of  disciples,  giving  rise, 
as  it  were,  to  .several  schools  of  infant  feeiling. 

The  attempts  to  explain  scientifically  the  good  results  of  these  empirical 
methods  have  not  always  been  bjtsed  uj>on  correct  premises,  but  the 
explanations,  however,  have  not  impaired  the  eflficiency  of  the  methods 
when  intelligently  applied,  although  they  have  added  materiallv  to  the 
.seeming  confusion  and  misunderstanding  which  surround  this  subject. 
The  methods  are  now  practically  confined  to  two: 

1.  Dilution  of  the  milk  with  water  and  the  addition  of  lime-water  or 
bicarbonate  of  soda — /.  e.,  dilution  with  alkaline  solutions. 

2.  Dilution  with  cereal  gruels,  which  are  fre(|uently  dextrinizcd. 
Hotii  reduce  by  dilution  the  amount  of  casein  in  the  mixture.     Both 

also  favor  curding  in  smaller  and  softer  flocculi,  but  each  influences  the 
digestif)n  of  the  casein  in  its  own  peculiar  wav. 

Alkaline  Diluents. — The  addition  of  alkalies  was  at  first  recommended 
.solely  with  the  idea  that  they  made  acid  cows'  milk  conform  more 
closely  to  a  suj)j)()sedly  alkaline  breast  milk.  Since  the  complete  demon- 
.stration  that  both  breast  milk  and  cows'  milk  are  acid,  the  original 
argument  for  the  use  of  alkalies  has  lost  its  force,  and,  unless  some  other 
good  reason  could  be  found  for  its  continuation,  such  use  would  be 
irrational.  Experience  has,  however,  ser-med  to  show  that  the  addition 
of  such  alkalies  was  essential  to  the  successful  feeding  with  cows'  milk 
when  water  was  used  as  the  diluent,  and  the  explanation  is  to  be  found 
in  the  fact  that,  aside  from  any  special  cft'ects  which  each  mav  have  upon 
the  curd,  alkalies  tend  to  retard  or  inlnl)it  the  action  of  the  rennet  ferment 
of  the  stomach  upon  the  casein.  The  alkalies  have  also  more  or  less 
effect  a,s  antacids  which  not  only  neutralize  any  lactic  acid  which  may 


SUBSTITUTE  INFANT  FEEDING  135 

have  been  formed  in  the  milk,  but  also  combine  to  some  extent  with  the 
acids  of  the  stomach,  preventing  to  a  greater  or  lesser  degree  their 
forming  tough  curds  with  the  paracasein,  so  that  less  digestion  will  be 
required  on  the  part  of  the  stomach. 

The  action,  then,  of  alkaline  diluents  is  a  chemical  one.  Dilution  of 
milk  with  cereal  gruel  is,  on  the  other  hand,  mechanical.  The  gelatinous 
properties  of  the  cooked  cereal  and  its  particles  of  cellulose  envelope 
the  flocculi  of  precipitated  casein,  preventing  their  tendency  to  coalesce 
into  dense  masses,  and  thus  allowing  more  complete  penetration  of  the 
digestive  juices. 

Cereal  Diluents. — It  has  been  urged  against  the  cereal  diluents  that 
starch  is  not  an  ingredient  of  breast  milk  and  that  the  starch-transforming 
functions  of  the  infant  are  not  fully  developed ;  but  we  must  accept  at 
the  outset  that  cows'  milk,  however  manipulated,  will  always  differ 
from  breast  milk,  and  the  dextrinization  of  gruels,  which  is  now  almost 
universally  used  for  young  infants,  supplements  the  action  of  the  devel- 
oping salivary  and  pancreatic  functions  in  preparing  the  starch  for 
absorption;  so  that  the  addition  of  cereals  which  enables  the  stomach 
to  digest  m.ore  casein  and  so  to  develop  by  the  exercise  of  its  normal 
functions,  is  both  justifiable  and  proper. 

Excellent  results  are  obtainable  by  both  methods,  and  where  either 
one  fails  the  other  may  be  successful.  We  should,  therefore,  take  no 
partisan  position,  but  be  familiar  with  the  use  of  each. 

Lime-water  as  the  Alkaline  Addition  to  the  Diluent. — The  usually 
accepted  percentage  of  lime-water  in  the  food  of  a  normal  infant  is 
5  per  cent.  This  is  secured  by  the  use  of  1  ounce  of  lime-water  in  every 
20  ounces  of  food  prepared,  which  would  he  \h  ounces  for  30  ounces  of 
food,  2  ounces  for  40  ounces,  and  2^  ounces  for  50  ounces.  In  writing 
directions  for  the  preparation  of  mixtures,  the  amount  of  lime-water  must, 
of  course,  be  subtracted  from  the  total  amount  of  diluent  required. 
For  example,  if  in  a  20-ounce  mixture  there  are  to  be  5  ounces  of  top 
milk  and  15  ounces  of  diluent,  we  write  for  5  ounces  top  milk,  1  ounce 
lime-water,  and  14  ounces  boiled  water. 

The  properties  of  lime-water  are  mainly  those  of  an  alkali ;  its  antacid 
value  is  small.  In  common  with  other  true  alkalies  it  has  the  property 
of  swelling  the  mucoid  proteid  of  milk,  thickening  it,  and  making  a 
visible  change  in  its  consistency.  It  therefore  has  a  definite  effect  upon 
the  precipitation  of  casein,  favoring  greater  flocculence  of  the  masses, 
and  consequently  rendering  them  more  readily  attacked  and  penetrated 
by  the  digestive  juices.  Its  second  and  probably  its  chief  influence  upon 
the  digestion  of  milk  consists  in  its  effect  as  an  alkali  in  retarding  the 
clotting  action  of  the  rennet  enzyme  of  the  stomach  upon  the  casein  of 
milk,  but,  being  a  weak  antacid,  it  is  soon  neutralized  by  any  acid  present. 
The  formation  of  the  paracasein  clot  is  slower  in  the  presence  of  an 
alkali  and  cannot  take  place  in  a  fully  alkaline  medium  until  the  alkali 
has  been  neutralized  or  removed.  Immediate  clotting  of  the  milk  in  the 
stomach  into  large  masses  which  are  soon  transformed  by  acid  into  firm 
curds  is  therefore  interfered  with  by  the  addition  of  lime-water.     The 


136  IXFAXT   FEKDISG 

degree  of  tliis  intorferenee  (lej)en(l.s  upon  the  proportion  of  the  Hme- 
water  to  the  amount  of  tlie  //////.•  contained  in  the  mixture.  Five  per 
cent,  of  hme-water  as  onhnariiy  used  in  food  mixtures  j)r()bahly  serves 
only  to  make  the  eurds  smaller  and  so  more  digestible  and  possibly  to 
delay  moderately  the  clotting  by  rennet. 

Cows'  milk  is  rendered  definitely  alkaline  to  phenolphthalein  by 
00  to  100  per  cent,  of  limi^-water,  or  nearly  ounce  for  ounce.  Inspection 
of  the  following  table  will  show  that  the  addition  of  10  per  cent,  of  lime- 
water,  often  recommended  for  use  in  the  feeding  mixtures  of  young 
infants,  gives  a  percentage  of  from  (30  to  200  per  cent,  of  lime-water  to 
the  milk  in  the  weaker  formula'. 

Table  Showing  Actital  A^jount  of  Bicarbonate  of  Soda  or  the  Percentage 

OF   LiME-WATEK   TO   THE    MILK   IN   MIXTURES   MaDE  WITH   TwO   GrAINS 

OF  Bicarbonate  of  Soda  to  the  Ounce  of  Mixture, 

OR    10    PER   CENT.  LiME-WATER. 


Per  cent. 

Grains  of  bicarbonate  of 

rt'ater. 

Milk. 

Lime- 

Bicarbonate 

Food. 

lirae- water. 

soda  to 

each  ounce 

V 

rater. 

of  soda. 

to  milk. 

of 

milk. 

17  oz. 

+ 

loz. 

+ 

2  oz. 

or      40  f?rs. 

-. 

20  oz. 

200  % 

40 

gr.s.  to  each  oz.  milk. 

IC  " 

+ 

2   " 

-t- 

2   " 

40    " 

.= 

20  " 

100    " 

20 

"         " 

15  " 

+ 

3  " 

+ 

2    " 

40    " 

^ 

20  " 

m%" 

13 

" 

14   " 

+ 

4   " 

+ 

2   " 

40    " 

= 

20  " 

50    " 

10 

"         " 

13  " 

+ 

5  " 

+ 

2    " 

40    " 

= 

20  " 

40    " 

8 

" 

12  " 

+ 

6   " 

+ 

2    " 

40    " 

'-= 

20  " 

3351" 

7 

" 

n  " 

+ 

7   " 

+ 

2    " 

40    " 

= 

20  " 

28    " 

6 

" 

10   " 

+ 

8   " 

+ 

2    " 

40     " 

= 

20  " 

25    " 

5 

" 

...  " 

+ 

18   •' 

+ 

2    " 

40    " 

= 

20   •' 

10    " 

2 

"         " 

Note. — The  use  of  one  ounce  of  lime-water  in  twenty  ounces  (5  per  cent,  of  lime-water)  or  cue 
grain  of  sodium  bicarbonate  to  each  ounce  of  the  mixture  gives  one-lialf  of  the  figures  in  the  last 
two  columns. 

The  employment,  then,  of  10  per  cent,  lime-water  in  the  food  of  young 
infants  containing  only  a  small  (piantity  of  milk  amounts  to  giving  them 
a  highly  alkalinized  milk,  which  will  be  but  slowly,  and  po.ssibly  even 
not  at  all,  clotted  and  curded  by  the  .secretions  of  the  stomach,  allowing 
some  of  the  work  of  digestion  to  fall  upon  the  intestine,  which  is  at 
this  time  better  fitted  for  the  purpose.  The  degree  of  alkalinization  with 
its  restraining  infiuence  upon  gastric  digestion  is  gradually  lessened  as 
the  child  takes  stronger  mixtures  containing  more  milk.  The  large 
percentage  of  lime-water  (10  per  cent.)  should  be  reduced  as  soon  as 
practicable  in  order  that  the  necessary  development  of  the  functions  of 
the  .stomach  should  not  be  unduly  retarded.  Lime-water  is  also  a  useful 
addition  to  the  food  where  there  is  a  tendency  to  vomiting  with  or  without 
loo.se  movements. 

Bicarbonate  of  Soda  as  an  Alkaline  Addition  to  the  Diluent. — Bicarbonate 
of  .soda  (baking  soda)  is  less  commonly  used  than  lime-water.  The  usual 
recommendation  is  to  add  it  in  the  proportion  of  1  grain  to  each  ounce 
of  food.  This  for  each  16  to  20  ounces  is  one-fourth  of  a  level  teaspoonful, 
or  as  large  a  pinch  as  can  be  taken  up  between  the  thumb  and  forefinger. 
The  impression  prevails  that  20  and  40  grains  of  sodium  bicarbonate  in 
20  ounces  of  food  mixture  are  the  exact  cHjuivalents  in  their  effects  of 


SUBSTITUTE  INFANT  FEEDING  137 

1  and  2  ounces  (5  per  cent,  and  10  per  cent.)  of  lime-water  in  20  ounces 
of  food  mixture.  This  is  in  certain  important  respects  an  error.  Chem- 
ically pure  sodium  bicarbonate,  if  obtainable,  would  be  an  antacid  only. 
Such  alkalinity  as  the  usual  sodium  bicarbonate  possesses  is  due  to 
impurities,  owing  to  loss  of  carbonic  acid  gas  and  the  reduction  of  some 
of  the  bicarbonate  to  the  carbonate  of  soda  (washing  soda),  which  is 
an  alkali.  This  was  recognized  by  the  United  States  Pharmacopeia, 
which  allowed  1  per  cent,  impurity  in  the  "purified"  and  5  per  cent,  in 
the  "commercial"  article.  The  alkalinity  in  solutions  increases  by 
standing,  agitation,  or  increase  of  temperature  above  59°  F.  Boihng 
converts  it  all  into  carbonate.  Bicarbonate  of  soda,  therefore,  reverses 
the  properties  of  lime-water  and  is  a  strong  antacid  and  a  more  or  less 
weak  alkali.  It  does  not  swell  the  mucoid  proteid  of  milk  as  does  lime- 
water,  but  if  the  carbonic  acid  gas  in  the  salt  has  not  been  driven  off 
by  previous  heating  of  the  food  the  gas  is  liberated  during  digestion, 
when  the  salt  meets  with  acid,  making  the  curd  more  porous.  Pasteur- 
izing or  sterilizing  the  food  converts  more  or  less  of  the  bicarbonate  into 
the  stronger  alkaline  carbonate.  Aside  from  their  respective  effects  upon 
the  mucoid  proteid  and  the  porosity  of  the  curd,  lime-water,  and  bicar- 
bonate of  soda  differ  chiefly  in  their  antacid  qualities.  As  ordinarily 
employed  in  the  amounts  of  20  grains  sodium  bicarbonate  or  1  ounce 
lime-water  to  20  ounces  of  food  mixture,  their  effects  as  alkalies  upon  the 
retardation  of  the  rennet  ferment  is  about  the  same,  but  to  secure  this 
amount  of  alkalinity  a  much  greater  amount  of  antacid  has  been  intro- 
duced in  the  sodium  bicarbonate;  1  ounce  lime-water  would  be  neutral- 
ized by  somewhat  less  than  1  ounce  of  adult  gastric  juice  of  0.2  acidity 
(HCl);  20  grains  sodium  bicarbonate  require  to  neutralize  them  about 
10  ounces  of  the  same  gastric  juice.  It  is  evident,  then,  that  a  longer  time 
must  elapse,  during  digestion,  with  sodium  bicarbonate  than  with  lime- 
water  before  an  acid  reaction  can  be  established  in  the  stomach.  The 
formation  of  acid  curds  of  paracasein  and  their  digestion  by  pepsin  are 
longer  delayed,  and  part  of  the  fluid  milk  escapes  into  the  intestine, 
lightening  the  burden  of  stomach  digestion.  Double  quantities  some- 
times recommended  for  young  infants — i.  e.,  2  grains  to  each  ounce — 
would  probably  cut  out  stomach  digestion  entirely.  For  this  reason 
sodium  bicarbonate  often  serves  us  better  with  children  of  difficult 
digestion.  It  is  easier  to  use  among  the  poor,  since  it  is  always  at  hand, 
and,  being  added  in  a  dry  form  and  dissolved  in  the  diluent,  does  not 
complicate  the  directions  as  does  lime-water.  It  may  also  be  chosen 
when  it  is  deemed  advisable  to  combine  the  use  of  an  alkaline  antacid 
with  that  of  a  cereal  diluent. 

Cereal  Diluents. — These  are  commonly  made  of  barley,  wheat,  or  oats, 
although  rice  and  arrow-root  may  be  used  in  certain  conditions.  Barley 
is  more  commonly  chosen  for  infants  under  seven  months  of  age  or  in 
any  tendency  to  relaxed  bowels.  Oatmeal  contains  more  tissue-building 
material  than  barley  and  may  be  selected  where  the  digestion  is  not 
disturbed  or  where  there  is  constipation.  Unless  contraindicated  it  is 
preferable  for  older  infants.    Wheat  flour  is  possibly  less  palatable,  non- 


138  INFANT  FEEDING 

laxative,  of  average  digestibility,  and  of  higher  nutritive  properties.  It 
is  used  both  for  younger  and  older  infants.  Cereal  gruels  are  employed 
both  plain  and  dextrini/ed.  Plain  gru(>ls  should  be  made  with  less 
cereal  for  young  infants,  since  they  contain  unchanged  starch.  "^I'hey 
may  be  made  with  more  cereal  when  adtled  in  relatively  small  amounts 
to  the  milk  of  older  infants,  since  the  resulting  jelly  will  be  thinned 
sufficiently  by  the  milk  and  the  starch-digesting  functions  are  then 
further  dcvelop(Ml.  Dcxtrinization  converts  the  raw  starch  into  soluble 
carb()]iy(h'atcs,  and  in  so  <h)ing  thins  the  gruel.  It  is  growing  in  favor 
witli  those  who  use  cereal  diluents  and  is  especially  adapted  to  use  for 
young  infants  whose  power  of  digesting  starches  is  at  best  very  slight. 
It  is  best  discontinued  when  the  amylolytic  function  develops  toward  the 
end  of  the  first  year.  In  acute  vomiting,  dextrinized  gruels  are  often 
retained  when  even  water  is  rejected.  Plain  cereal  waters  and  cereal 
jellies  are  made  by  using  different  quantities  of  the  cereals  with  the 
same  amount  of  water.  Either  prepared  flour  or  the  grains  may  be 
used,  but  the  latter  rccjuire  at  least  three  hours  boiling. 

Cereal  Waters. — Cereal  waters  are  made  most  easily  by  using  the 
prepared  Hours:  Rol)inson's  Patent  Barley  Flour,  the  barley  flour  and 
oatmeal  Hour  of  the  Health  Food  Company,  New  York;  Hubbell's 
Prepared  Wheat  Flour,  and  Imperial  Granum.  All  of  these  have  been 
partially  prepared  by  heat,  but  the  length  of  time  recommended  for 
cooking  in  their  directions  is  best  exceeded.  Ordinary  wheat  flour, 
rice  Hour,  or  arrow-root  may  also  be  used.  To  make  such  a  water 
(thin  gruel),  stir  one  heaping  teaspoonful  of  the  Hour  into  a  little  cold 
water  until  no  lumps  remain.  Add  this  to  one  pint  of  boiling  water  and 
cook  at  least  twenty  minutes,  pi-eferably  in  a  double  boiler  (Fig.  26), 
stirring  constantly.  One  or  two  ounces  of  the  water  will  boil  away  and 
this  may  be  replaced.  Add  a  pinch  of  salt  and  strain  through  a  wire 
strahicr  to  remove  coarse  particles. 

Cereal  Jellies. — These  require  one  heaping  tablespoonful  of  Hour  to  a 
pint  of  water,  but  are  otherwise  made  the  same  way. 

By  the  use  of  a  good  type  of  steam-cooked,  Haked  or  rolled  oats,  an 
oatmeal-water  or  jelly  may  be  made  by  using  double  the  quantities 
mentioned  for  the  Hour  and  the  same  amount  of  water,  and  boiling 
thirty  minutes,  straining,  etc. 

Dextrinized  Gruels. — Depending  upon  the  age  of  the  child  and  the 
quantity  to  be  used  in  the  food,  one  heaping  teaspoonful  to  one  heaping 
tablespoonful  is  cooked  as  above  in  one  pint  of  boiling  water  for  fifteen 
to  twenty  minutes.  The  dish  is  then  set  in  cold  water  until  the  contents 
are  just  cool  enough  to  be  tasted  when  the  dextrinizing  agent  is  added; 
stir  and  keep  warm  until  the  gruel  becomes  thin,  after  which  add  a 
pinch  of  salt,  strain  and  cool.  Various  preparations  of  diastase  may 
be  used  for  this  purpose,  but  that  chiefly  employed  by  those  who  advocate 
dcxtrinization  is  a  glycerinated  solution  of  diastase  under  the  name  of 
Cereo,  of  which  thirty  drops  suffice  to  convert  a  pint  of  gruel.  A 
sufficient  (juantity  of  gruel  for  twenty-four  hours'  use  should  be  made 
freshly  each  day. 


SUBSTITUTE  INFANT  FEEDING  139 

All  cereal  diluents  must  either  be  cool  before  they  are  mixed  with  the 
milk  or,  if  added  warm,  the  food  must  be  quickly  cooled,  since  warmth 
favors  bacterial  growth  in  the  milk.  If  the  milk  is  to  be  heated  at  all, 
as  in  summer,  it  will  blend  better  with  certain  of  the  plain  gruels  when 
it  is  added  to  them  while  they  are  still  hot,  in  which  case  the  mixture 
should  again  be  heated  to  just  short  of  the  boiling  point,  stand  twenty 
minutes  for  pasteurizing,  and  then  be  promptly  cooled. 


PREPARATION  OF  THE  INFANT'S  FOOD. 

In  the  city  it  is  essential  to  secure  "certified  milk"  or  a  good,  clean, 
fresh  milk  from  a  known  source,  bottled  at  the  farm.  In  the  country 
completely  fill  with  fresh  strained  milk  a  clean  quart  milk  bottle  or 
quart  preserving  jar,  seal,  and  set  in  ice  or  in  cool  running  water 
overnight,  or  for  at  least  four  hours.  Make  this  period  the  same  each 
day  in  order  that  the  cream  may  rise  to  the  same  extent.  Remove  with 
a  Chapin  dipper  or  pour  from  the  top  the  requisite  number  of  ounces 
of  top  milk  to  secure  the  desired  ratio  of  fat  to  proteids  and  place  in  an 
absolutely  clean  bowl,  glass  pitcher,  or  graduate,  and  devote  the  remain- 
der of  the  milk  to  other  household  purposes.  Of  this  top  milk  so  removed, 
again  measure  the  desired  number  of  ounces  (dippers)  needed  for  the  feed- 
ing for  twenty-four  hours.  Add  to  this  the  measured  amount  of  boiled 
water,  lime-water  (or  bicarbonate  of  soda),  or  of  the  cereal  gruel  deter- 
mined upon  as  the  amount  of  the  diluent.  Dissolve  the  sugar  in  the  water. 
Have  as  many  bottles  as  there  will  be  feedings  in  the  twenty-four  hours. 
Mix  and  pour  into  each  of  these  the  amount  required  for  a  single  feeding. 
Stopper  with  clean  absorbent  or  baked  non-absorbent  cotton,  pasteurize, 
and  cool  in  running  water  if  necessary.  Finally  place  the  bottles  on  ice 
or  keep  them  at  a  temperature  below  50°  F.  Immediately  before  the 
feeding  time  remove  the  cotton  stopper,  adjust  the  nipple,  heat  to  blood 
heat  by  placing  in  moderately  hot  water,  test  the  temperature  by  allow- 
ing a  few  drops  to  fall  from  the  nipple  upon  the  inner  surface  of  the 
wrist,  and,  after  feeding,  reject  any  milk  which  may  remain.  Never 
make  a  double  quantity  in  one  bottle,  never  feed  a  second  time  from  a 
bottle  which  has  once  been  warmed  up. 

If,  as  frequently  happens  among  the  poor,  it  be  impossible  to  secure 
so  much  attention  to  detail,  considerable  security  may  be  obtained  by 
having  the  daily  supply  of  food,  when  mixed,  placed  in  a  saucepan  and 
brought  up  to  a  point  just  short  of  boiling,  allowed  to  stand  covered 
twenty  minutes,  and  then  poured  into  well-scalded  quart  milk  bottles  or 
preserving  jars,  which  are  then  sealed,  rapidly  cooled  in  running  water, 
and,  when  cooled,  kept  on  ice  or  in  the  coolest  place  available.  Although 
there  are  opportunities  for  contamination  from  repeated  opening  of  such 
bottles  to  remove  the  portions  required  for  each  feeding,  there  wdll,  if 
the  bottle  is  shaken  each  time,  be  greater  uniformity  in  the  food  and 
vastly  greater  protection  from  contamination  owing  to  the  heating  of 
the  milk  soon  after  its  receipt  than  is  usually  the  case  when  the  food  is 


140  IXFAXT   FEEDIXG 

mixed  for  each  feeding  from  materials  wliieh  have  been  more  or  less 
exposed  throuijhout  the  (hiy.  Milk  should  not  he  kept  in  an  open  vessel, 
even  in  a  refrijjerator,  since  it  readily  absorbs  oilors  and  noxious  (|ualities, 
^luch  less  should  it  stand  uncovered  in  a  room  or  on  a  window-sill, 
expos(>d  to  dust. 

Choice  and  Care  of  Bottles. — Tall  cylindrical  botdes  with  asufficiently 
wide  neck  to  allow  of  easy  cleansing  are  preferal)le  to  other  shapes  and 
suited  for  us<*  in  the  ordinary  forms  of  pasteurizers.  The  markings  upon 
such  bottles  are  more  nearly  accurate  than  upon  other  shapes.  Small 
bottles  are  made,  but  those  containing  S  ounces  serve  until  the  end  of 
the  first  year,  when  larger  ones  may  be  substituted.  After  feeding,  the 
bottle  should  be  rinsed  free  from  all  vestiges  of  milk  with  cold  water  and 
then  rinsed  in  scalding-hot  water  and  inverted  to  dry.  Before  again 
using  to  make  up  the  daily  supply  of  food,  they  may  be  Ixjiled;  but  if 
previously  well  cleaned  as  directed,  rinsing  in  hot  boiled  water  will 
suffice. 

Choice  and  Care  of  Nipples. — Those  made  of  black  rubber  are  the 
best.  It  shoulil  be  possible  to  turn  them  inside  out  when  cleansing. 
They  should  fit  directly  upon  the  neck  of  the  l)ottle  and  have  no  compli- 
cated valves  or  tubing.  The  single  perforation  in  the  tip  should  allow 
the  milk  to  drop  when  the  bottle  is  turned  down,  for  if  it  runs  in  a  stream 
the  infant  will  take  the  food  too  fjuickly.  As  soon  as  the  feeding  is 
finished  the  nij)])le  should  be  washed  carefully  inside  and  out  with  cold 
water,  then  in  hot  water,  and  placed  in  a  cup  of  water  containing  a  large 
pinch  of  borax  or  bicarbonate  of  soda.  So  cared  for,  boiling,  which 
softens  the  rubber,  should  be  only  exceptionally  necessar}*.  Two  nip- 
ples may  be  used  alternately  and  renewed  from  time  to  time.  Nipples 
that  are  cracked  or  where  the  hole  is  large  should  be  discai'ded. 

Bottle  Cosies. — For  young  and  delicate  infants  and  in  cool  weather, 
especially  for  those  who  take  their  food  slowly,  it  is  often  well  to  provide 
small  flamiel  or  canton-flannel  bags  to  .slip  over  the  bottle  closely  and 
tie  about  the  neck  with  a  drawstring.  These  aid  in  maintaining  the 
proper  temperature  in  the  food,  which  otherwise  may  cool  rapidly  before 
it  is  all  taken.  Undue  cooling  may  either  disturb  digestion  or  cause 
the  child  to  refuse  the  full  amount.  Such  bags  should  be  kept  scru- 
pulously clean  by  frecpient  washing,  as  they  become  wet  with  the  food, 
which  soon  sours.  On  the  other  hand,  food  should  never  be  warmed 
except  for  immediate  use.  Food  warmers  which  keep  the  food  warm 
several  hours  at  night,  to  save  lazy  and  ignorant  nurses  or  parents  from 
getting  out  of  bed,  are  simply  incubators  for  developing  swarms  of 
bacteria  even  in  pasteurized  and  sterilized  milk,  and  are  often  the  cause 
of  much  serious  disturbance. 


DETERMINATION  OF   FOOD   PROPORTIONS. 

To  secure  feeding  formula',  tables  are  frequently  printed  giving  the 
exact  proportions  of  milk,   water,  sugar,  etc.,  required  to  produce  a 


SUBSTITUTE   LXFAXT  FEEDIXG 


141 


definite  number  of  ounces  of  certain  fat  and  proteid  ratios  presumedly 
adapted  to  the  infant  during  given  periods  of  its  existence.  These, 
while  undeniably  of  assistance  to  the  physician  whose  sole  wish  is  to 
secure  most  easily  a  food  prescription  for  a  baby,  tend  directly  to  per- 
petuate the  fallacy  that  a  child  of  so  many  months  ^v^ll  or  should  be  able 
to  digest  the  particular  formulae  outlined.  To  secure  any  real  degee  of 
success  in  feeding  infants,  which  only  comes  with  the  ready  ability  to 
\diT\  the  proportion  of  each  ingredient  of  the  formulae,  the  practitioner 
must  learn  to  make  his  own  formulae  as  he  must  learn  to  write  his  own 
medical  prescriptions.  The  most  concise  aid  for  this  is  the  following 
table  freely  adapted  from  that  of  Dr.  J.  F.  Connors: 


Key 

TO  H 

OME 

Modification  of  Bottled  Milk. 

Per  cent, 
proteids. 

Per  cent.  fat. 

Per  ct. 
sugar. 

Proportions  of  mil 
diluent  in  feed! 
mixtures. 

kand 

-•2  . 

■|s4 

1 

1 
% 

g 
a 
3 

m 

1 

OS 

1 
0 

"3 

oog 

i| 

1.0  s 
'IS 
as 

.-1  0 

OS 

°ig 

as 

^1 

go 

t 

0 
<u 

0 

.a 

■a 
©  . 

a^ 

Bo 

ng 

o  £  a 

y  ^-  " 
III 

a 

a 
0 

S~t 

0 

3 
p. 
0 

i 
a 

4.^ 

2 

.2 

S 

0 

0.25 

0.22 

0.06 

0.25 

0.37 

0.50 

0.62 

0.75 

0.87 

LOO 

0.31 

1/16 

1 

15 

16 

0.33 

0.29 

0.08 

0.33 

0.50 

0.67 

0.83 

LOO 

L17 

L33 

0.42 

V12 

1 

11 

12 

0.50 

0.44 

0.13 

0.50 

0.75 

1.00 

1.25 

L50 

1.75 

2.00 

0.62 

Va 

1 

7 

8 

0.57 

0.50 

0.14 

0.57 

0.86 

1.14 

1.43 

L71 

2.00 

2.30 

0.70 

V7 

1 

6 

7 

0.67 

0.60 

0.17 

0.67 

1.00 

1.33 

1.67 

2.00 

2.34 

2.67 

0.83 

Ve 

1 

5 

6 

0.86 

0.70 

0.20 

0.86 

1.20 

1.60 

2.00 

2.40 

2.80 

3.20 

LOO 

Vs 

1 

4 

5 

1.00 

0.90 

0.25 

1.00 

1.50 

2.00 

2.50 

3.00 

3.50 

4.00 

1.25 

Vi 

1 

3 

4 

1.14 

1.00 

0.29 

1.14 

1.70 

2.30 

2.85 

3.45 

4.00 

4.60 

L43 

"h 

1 

2% 

3K 

1.33 

1.16 

0.33 

1.33 

2.00 

2.67 

3.33 

4.00 

4.66 

5.33 

1.66 

Vs 

1 

2 

3 

1.60 

1.40 

0.40 

1.60 

2.40 

3.20 

4.00 

4.80 

5.60 

6.40 

2.00 

2/5 

2 

3 

5 

2.00 

1.75 

0.50 

2.00 

3.00 

4.00 

5.00 

6.00 

7.00 

8.00 

2.50 

1/2 

1 

1 

2 

2.50 

2.20 

0.62 

2.50 

3.75 

5.00 

6.25 

7.50 

8.75 

10.00 

3.12 

% 

5 

3 

8 

2.67 

2.33 

0.67 

2.67 

4.00 

5.33 

6.67 

8.00 

9.33 

10.67 

3.33 

% 

2 

1 

3 

3.00 

2.62 

0.75 

3.00 

4.50 

6.00 

7.50 

9.00 

10.50 

12.00 

3.75 

«/* 

3 

1 

4 

3.20 

2.80 

0.80 

3.20 

4.80 

6.40 

8.00 

9.60 

U.20 

12.80 

4.00 

^/o 

4 

1 

5 

Note. — The  proteids  have  been  calculated  upon  the  basis  of  both 
4  per  cent,  and  3.50  per  cent.  The  former,  4  per  cent.,  is  for  those  who 
use  round  numbers  to  facilitate  mental  calculation  of  percentages.  The 
latter,  3.50  per  cent.,  which  is  the  actual  percentage  of  proteids  in  good 
average  milk  having  4  per  cent,  fat,  is  to  enable  the  practitioner  to 
determine  readily  the  more    exact    amount  of  proteids  in  any  given 


142 


IXFAXT  FEEDING 


mixture.  Either  column  may  he  us(^(l  for  the  purpose  of  making  a 
mixture  of  any  desired  percentages,  or  in  deternnning  the  percentages 
contained  in  any  mixture  of  known  proporticMis.  To  make  up  any 
desired  percentage  mixture  (1)  find  in  the  one  of  the  proteid  coknnns 
determined  upon  the  desired  percentage,  or  that  which  is  nearest  to  it; 
(2)  move  in  a  horizontal  line  to  the  right  until  the  desired  percentage 
of  fat  is  readied,  or  one  which  is  nearest  to  it;  (3)  the  heading  of  this  fat 
column  tells  what  kind  of  milk  is  to  be  used;  (4)  on  the  same  line  with  the 
fat  percentage  at  the  right  will  be  found  the  fraction  showing  the  neces- 
sary proportions  of  this  milk  or  top  milk  in  the  food  mixtures  to  give  the 
percentages  selected,  and  beyond  this  will  be  found  the  number  of  parts 
of  such  milk  or  top  milk  and  of  diluent  (see  p.  134)  which  must  be 
used;  (5)  dij)  off  the  proper  milk  and  ililute  all  or  a  part  of  it,  depending 
on  the  quantity  of  the  food  to  be  made  up;  (B)  the  addition  of  2\  fairly 
level  tablespoonfuls  of  milk-sugar  or  2  exactly  level  tablespoonfuls  of 
granulated  sugar  for  about  every  20  ounces  of  the  total  mixture  (see 
p.  133)  will  give  the  proper  percentages  of  sugar. 

Of  almost  cfiual  importance  to  the  selection  of  proper  j)roportions 
for  the  infant's  food  is  the  giving  of  the  food  in  proper  amounts  antl  at 
proper  intervals. 

QUANTITY  OF  FOOD. 

Authorities  agree  that  the  capacity  of  the  stomach  of  the  newborn 
infant  of  average  weight  is  about  one  ounce.  Under  the  stimulus  of  its 
newlv  assumed  functions  the  stomach  develops  rapidly  during  the  first 
three  or  four  months,  the  period  during  which,  under  normal  conditions, 
the  increase  of  body  weight  is  also  the  most  rapid.  During  the  fifth  to 
sixth  months  the  rate  of  increase  of  both  stomach  capacity  and  weight 
is  distinctly  less,  but  it  thereafter  again  increases,  although  more  slowly 
than  in  the  early  months.  Attempts  to  estimate  average  capacities  at 
different  periods  necessarily  give  varying  results,  owing  to  the  different 
methods  employed  and  the  conditions  under  AA-hich  the  estimates  are 
mafle.  But  although  these  results  .show  considerable  latitude,  they  are 
sufficient  to  allow  of  the  construction  of  a  table  for  our  guidance. 

Schedule  for  ax  AVERAGE  HEALTHY  INFANT,  showing  Quantities, 
Number,  and  Intervals  of  Feedings.    (Holt.) 


Quantity  for 

Number  feedings 

Age. 

one 

feeding. 

in  twenty-four 

Interval 

Ounces. 

hours. 

by  day. 

Premature  infants    . 

•      ^' 

to    % 

12  to  18 

1  to  1)2  hours. 

First  to  fourth  day    . 

.    1 

"   13< 

6    "    10 

2    "    4 

Fifth  to  seventh  day 

.    1 

"    2 

10 

2 

Second  week     . 

2 

^'    2% 

10 

2             " 

Third  week 

.    2 

"  z'A 

10 

2 

Fourth  to  eighth  week    . 

.    -2% 

"    4 

9 

2}^         " 

Third  month     . 

.    3 

"    5 

8 

2)^          " 

Fourth  month  . 

.     3'^ 

"  53^ 

7 

3 

Fifth  month 

.    4 

"    6 

7 

3 

Sixth  to  tenth  month 

.     5 

"    8 

6 

3 

Eleventh  month 

.     C 

"    9 

5 

4 

Twelfth  month 

7 

'•    9 

5 

4 

Thirteenth  month    . 

7 

••  10 

5 

4 

SUBSTITUTE  INFANT  FEEDING  143 

Nursed  infants  of  the  same  age  often  take  and  often  can  only  secure 
very  different  amounts  from  the  breast.  But  tlie  thorough  utihzation 
of  breast  milk  in  digestion,  and  the  more  concentrated  nature  of  the 
maternal  milk,  which  leads  sooner  to  satiety  as  compared  with  the  weak 
modifications  of  cows'  milk  a  young  infant  can  digest,  render  the  adjust- 
ment between  capacity  and  supply  more  automatic  than  in  bottle  feeding, 
so  that  the  danger  of  overfilling  the  stomach  is  minimized.  This  danger, 
on  the  contrary,  is  a  very  real  one  in  bottle  feeding.  An  overfilled 
stomach  cannot  properly  carry  on  its  secretive,  digestive,  and  mechanical 
functions.  jNIuch  failure  in  infant  feeding  is  due  to  this  cause  alone, 
even  when  other  conditions  are  such  as  to  favor  success.  It  is  so  common 
an  error  that  the  danger  should  always  be  kept  in  mind.  Although 
bottle-fed  infants  probably  require  rather  more  of  their  necessarily  dilute 
food,  more  perfect  digestion  will  undoubtedly  be  secured  by  keeping  the 
amount  very  close  to  that  taken  by  the  nursing  infant.  But  since  the 
rate  of  body  growth  and  the  size  of  the  stomach  show  a  certain  degree 
of  relation,  the  published  table  allows  moderate  latitude  for  different 
children  at  the  same  age.  However,  unless  the  rapid  growth  of  the 
infant  distinctly  indicates  an  approach  to  the  larger  amount,  conserva- 
tism will  lead  to  the  adoption  of  the  smaller  amounts  or,  at  most,  of  a 
middle  course. 

THE  INTERVAL  OF  FEEDING. 

The  establishment  of  definite  hours  of  feeding  contributes  largely  to 
success.  (See  schedule,  p.  142.)  Irregularity  has  even  more  of  a  pernicious 
effect  upon  the  infant  than  upon  the  adult.  Although  in  bottle  feeding 
lack  of  uniformity  in  the  strength  of  the  food  does  not  play  a  part  as  it 
does  when  the  breast  is  given  to  the  infant  at  irregular  intervals,  still  bottle 
feedings  should  be  given  by  the  clock,  and  the  infant  should  be  waked 
if  asleep,  since  habit  is  an  important  factor  in  influencing  the  demands 
of  the  infant  and  its  well-being.  During  the  first  three  days,  aside  from 
the  water  it  is  given,  a  breast-fed  infant  receives  sufficient  nourishment 
from  the  colostrum,  which  it  derives  from  the  breast  at  intervals  which 
are  at  first  longer  than  those  inaugurated  after  the  milk  begins  to  flow. 
With  the  infant  which  must  be  bottle  fed  from  birth,  the  giving  of  a 
suitably  dilute  modification  should  be  promptly  begun,  with  an  interval 
dependent  upon  circumstances  of  at  first  four  and  then  soon  of  two 
hours,  since  the  education  of  the  stomach  for  this  kind  of  food  must  be 
begun  with  care,  and  because  at  best  the  recovery  of  the  normal  loss  of 
weight  after  birth  and  the  establishment  of  a  regular  gain  is  slower 
with  the  bottle  fed.  The  two-hour  interval  suitable  for  the  first  three 
weeks  should,  however,  at  the  fourth  week  give  way  to  a  longer  interval 
of  two  and  a  half  hours,  and  this  at  the  fourth  month  to  three  hours. 
This  lengthening  of  the  intervals  is  for  two  reasons:  first,  that  the 
quantity  and  strength  of  the  food  are  increased;  second,  that  as  the 
stomach  takes  on  greater  powers  of  digesting  the  food  its  secretions  act 
upon  the  milk,  forming  compounds  Vvhich  remain  longer  in  that  organ. 


144  I.\FA.\T   FEICDISG 

Time  should,  therefore,  be  <;iven  for  the  stomach  to  empty  itself  before 
another  feeding  is  given.  This  is  usually  longer  with  cows'  milk  than 
breast  milk. 

Number  of  Feedings  in  Twenty-four  Hours. — These  l)ear  a  relation 
both  to  the  aiuount  of  food  and  to  the  length  of  the  interval,  and  they 
decrease  as  the  infant  grows  older.     (See  schedule,  p.  142.) 

Night  Feedings. — During  the  first  month,  while  the  total  number 
of  feedings  is  ten  and  the  interval  is  two  hours  in  the  daytime,  two 
feedings  may  be  given  at  longer  intervals  during  the  night  hours  from 
9  P.M.  to  7  A.M.  When  the  number  is  reduced  to  nine  at  the  beginning 
of  the  second  month  and  the  interval  is  mafle  t\\'o  and  one-half  hours, 
only  one  of  these  feeilings  should  be  given  during  the  night.  Feedings 
at  night  should  be  discontiinied  at  the  beginning  of  the  fourth  month, 
when  the  bottles  are  seven  in  number  and  the  interval  three  hours. 
The  first  morning  feeding  may  be  at  G  or  7  a.m.,  and  the  last  be  given 
at  9  or  10  p.m.  If  the  infant  wakes  during  the  night  and  is  thirsty, 
plain  boiled  water  may  be  offered.  Elimination  of  the  night  feedings, 
bv  p(>rmitting  uiulisturbed  sleej)  and  allowing  the  digestive  organs  a 
prolonged  rest,  is  distinctly  beneficial  to  the  infant. 


FEEDING  THE  NORMAL  INFANT  FROM  BIRTH. 

When  necessity  dictates  that  the  infant  must  be  artificially  fed  from 
birth,  certain  principles  are  now  generally  accepted  which  are  applicable 
to  the  majority  of  normal  infants.  It  is  recognized  that  such  an  infant 
can  assimilate  a  larger  amount  of  fat  than  proteids,  since  the  fat  is 
absorbed  with  little  change,  but  the  proteids  must  be  digested.  Since  this 
is  an  especially  difficult  function  for  the  stomach  to  acquire  when  cows' 
milk  replaces  breast  milk,  the  initial  amount  of  proteids  in  the  modifi- 
cation should  not  exceed  0.25  to  0.33  per  cent,  upon  the  first  day,  and  this 
amount  should  be  gradually  increased,  carrying  with  it  a  proportionate 
increase  of  the  fat.  The  accepted  ratio  of  fat  to  proteids  for  the  first 
three  to  four  months  is  three  times  as  much  fat  as  proteid  (12  per  cent, 
top  milk,  or  upper  third  of  bottle).  From  about  the  fourth  month  to 
toward  the  end  of  the  first  year,  the  proportion  may  then  be  fat  double 
the  proteids  (8  per  cent,  top  milk,  upper  half-bottle),  and  from  that  time 
on  equal  fat  and  proteids  (plain  milk).  Such  progression  is  best  shown 
by  the  accompanying  table  from  Holt.     (See  p.  145.) 

Pvxact  |)ercentages,  such  as  are  shown  in  the  table,  can  only  be  secured 
by  prescription  feeding  with  the  aid  of  a  milk  lal)oratory,  but  approxi- 
mate results  which  will  serve  the  pur})ose  in  the  average  case  may  be 
obtained  by  the  dilution  of  various  strengths  of  top  milk.  Here,  again, 
it  should  be  stated  that  such  schedules  of  percentages  are  intended  only 
for  the  general  instruction  of  the  practitioner  as  to  the  amounts  of  fat 
and  proteids  which  the  average  healthy  infant  may  be  able  to  take  at 
these  periods  and  those  ratios  which  are  more  commonly  successful; 
but  these  depend  so  largely  upon  the  healthy  digestion  of  the  infant 


SUBSTITUTE  IXFAXT  FEEDIXG 


145 


and  the  care  with  vrhich  it  has  been  fed  at  eacli  stage  that  variations  are 
very  frequently  necessary.  Whatever  criticism  modified  milk  and 
percentage  feeding  have  received  in  the  past  has  arisen  from  the  attempts 
of  the  physician  to  make  the  infant  fit  the  formula  rather  than  to  find 
intelligently  the  proper  formula  for  the  infant.  The  needs  of  each 
infant  must  be  studied  by  themselves,  and  increase  or  decrease  of  anv  of 
the  elements  of  its  food  made  after  careful  consideration  of  its  digestion, 
stools,  body  weight,  and  general  well-being.  A  schedule  of  percentages 
then  serves  simply  as  a  guide  which  may  be  consulted  to  see  how  near 
we  are  approaching  in  the  individual  case  to  the  averages  which  have 
been  found  advisable  to  secure  normal  ^^'ell-balanced  nutrition  for  an 
average  infant.  A  large,  vigorous  infant  and  one  that  is  small  and 
delicate  require  different  handling,  but  with  such  a  schedule  before  us 
we  shall  be  less  liable  to  overfeed  or,  what  is  a  still  more  serious  error,  to 
continue  too  long  food  which  contains  insufficient  amounts  of  heat- 
producing  and  tissue-building  elements. 

Schedule  for  .ix  AVERAGE  HE.ALTHY  INFANT,  showing  Percentages  of 

Fat,  Sugae,  a^d  Proteids,  a^"d  Quaxtities.     (Holt.) 


Age. 

Percentages  of 

Quantity  for  one 
feeding. 

No.  of 
feedings 

In 
24  hours. 

Interval  by 
day. 

Fat. 

Sugar. 

Proteids. 

Ounces. 

Grams. 

Premature  infants, 

1.00 

4.00 

0.25 

Kto  Vi 

7  to    22 

12  to  18 

1  to  1%  his. 

First  to  fourth  day, 

1.00 

5.00 

0.30 

1"1K 

30  "     45 

6  "  10 

2  "  4  hours. 

Fifth  to  seventh  day, 

1.50 

5.00 

0.50 

1"2 

30   "     60 

10 

2      " 

Second  weeix, 

2.00 

6.00 

0.60 

2"2K 

60   "     75 

10 

2      " 

Third  week, 

2.50 

6.00 

0.80 

2"S% 

60   "   110 

10 

2      " 

Fourth  to  eighth  \veek, 

3.00 

6.00 

1.00 

2J^"4 

75   "  125 

9 

2K" 

Third  month, 

3.00 

6.00 

1.25 

3  "5 

90   "   155 

8 

2K" 

Fourth  month, 

3.50 

7.00 

1.50 

oV,  "  oy. 

110   "   170 

7 

3      " 

Fifth  montb, 

3.50 

700 

1.75 

4-'  0 

125  "   185 

7 

3      " 

Sixth  to  tenth  month, 

■1.00 

7.00 

2.00 

5"S 

155  "   250 

6 

3      " 

Eleventh  month. 

1.00 

5.00 

2.50 

0"9 

185  "  280 

5 

4      " 

Twelfth  month, 

4.00 

5.00 

3.00 

7  "  9 

220   "   280 

5 

4      " 

Thirteenth  month, 

4.00 

4.00 

3  50 

7  "  10 

220   "   .310 

5 

4      " 

Feeding  of   the    Average   Normal   Case   from  Birth.— It  is   of 

the  highest  importance  that  an  infant  who  is  to  be  artificially  fed 
should  be  started  rightly,  and  that  normal  digestion  be  maintained 
during  the  critical  period  of  the  first  three  months.  Started  rightly  the 
infant  usually  progresses  favorably,  while  the  digestion  once  upset  is 
often  very  difiicult  to  restore.  For  this  reason,  if  we  have  good  and 
sufficient  grounds  for  beheving  that  the  mother  cannot  nurse  her  infant 
satisfactorily  even  for  a  short  time,  better  results  are  attained  bv  imme- 
diately beginning  artificial  feeding  at  birth,  before  the  infant  has  lost 


14()  INFANT  FEEDING 

ojround  upon  a  hopeless  milk.  To  secure  for  sueh  an  infant  10  feedings 
of  1  ounce  each,  to  be  given  every  two  hours,  antl  containing  about 
1  per  cent,  fat,  5  per  cent,  sugar,  0.33  per  cent,  proteids,  we  refer  to  the 
table,  p.  141,  and  find  that  we  must  use  1  part  of  a  "9-ounce  top  milk" 
and  11  parts  of  diluent.  We  woukl  then  remove  with  the  1-ounce 
Chapin  dipjxM-  0  ounces  from  the  top  of  a  (juart  bottle  of  good  average 
milk  upon  which  the  cream  has  risen,  mix  them  and  use  for  the  infant's 
food  1  ounce  of  this  "9-ounce  top  milk,"  1  ounce  lime-water  (10  per 
cent,  of  mixture),  Ij  level  tablespoonfuls  of  milk-sugar,  and  10  ounces 
of  boiled  water.  Put  1  ounce  of  this  mixture  in  each  of  10  nursing 
bottles,  stopper  with  cotton,  and  pasteurize  if  deemed  advisable. 
If  dextrinized  barley-water  (see  p.  138)  is  preferred,  use  1  ounce 
of  the  "9-ounce  top  milk"  with  11  ounces  of  this  diluent  and  add  the 
sugar.  When  we  wish  to  increase  the  strength  of  the  food  in  both  fat 
and  proteids,  and  to  give  larger  quantities  in  each  bottle,  we  continue  to 
use  the  same  "9-ounce  top  milk,"  and  instead  of  making  it  one-twelfth 
of  the  mixture  we  make  it  one-tenth,  one-eighth,  one-seventh,  etc.,  of 
the  mixture,  and  prepare  for  the  day  any  convenient  quantity  which  is 
slightly  in  excess  of  our  needs,  and  after  placing  the  recjuired  amount 
in  each  bottle  reject  the  surplus.  If,  for  any  reason,  it  is  deemed 
advisable  to  change  the  proportion  (3:1)  of  the  fat  to  proteids,  this 
is  accomplished  by  choosing  a  different  "top  milk" — a  stronger  one 
(less  ounces  off  top)  to  increase  the  fat  proportion  and  a  weaker  one 
(more  ounces  off  top)  to  decrease  it.  Whatever  the  total  amount  of 
food  made  for  the  day  we  use  milk-sugar  in  tlie  proportion  of  2V 
level  tablespoonfuls  for  about  every  20  ounces  of  food  mixture;  and 
if  we  employ  lime-water,  2  ounces  of  it  in  every  20  ounces  of  food 
(10  per  cent.)  until  good  digestion  is  established,  and  then  1  ounce  of 
lime-water  to  every  20  ounces  of  food  (5  per  cent.),  both  of  these  quanti- 
ties of  lime-water  being  counted  in  among  the  ounces  of  the  diluent. 
Since  the  infant  must  first  learn  to  digest  cows'  milk,  beginning  v*'ith 
percentages  of  the  dissimilar  proteids  much  lower  than  those  in  breast 
milk,  we  must  neither  expect  the  same  stools  nor  the  same  prompt 
gain  in  weight  as  in  a  breast-fed  infant.  Our  primary  aim  is  not  to 
give  certain  exact  percentages,  but  to  secure  good  digestion,  which 
is  best  indicated  by  the  comfort  and  sleep  of  the  infant;  and  to  push 
both  the  strength  and  quantity  of  the  food  forward  as  rapidly  as  the 
infant  can  take  care  of  it,  so  that  the  infant  who  was  started  with  fat  1 
per  cent.,  sugar  5  per  cent.,  proteids  0.33  per  cent,  at  birth  shall  be  taking 
3  to  3.50  per  cent,  fat,  (5  per  cent,  sugar,  and  l.oO  per  cent,  proteids  at  the 
begiiming  of  the  fourth  month,  and  fat  4  per  cent.,  sugar  7  per  cent.,  pro- 
teids 2  per  cent,  by  the  middle  of  the  year.  Since  more  than  4  per  cent, 
fat  is  liable  to  disturb  digestion,  it  will  be  thus  seen  that  after  the  fat 
reaches  3..")()  percent,  the  proteids  are  pushed  up  more  rapidly  than  the 
fat,  being  half  the  amount  of  the  fat  at  five  to  six  months,  and  approach- 
ing equality  during  the  last  few  months  of  the  year.  Increases  in  quan- 
tity and  strength  should  not  be  made  with  the  suddenness  apparently 
indicated  by  all  schedules,  but,  when  necessary,  should  be  made  gradu- 


SUBSTITUTE  INFANT  FEEDING  147 

ally,  covering  several  days.  It  is  a  safe  plan  when,  with  good  digestion, 
the  infant  is  not  satisfied  with  the  bottle,  to  first  increase  slightly  the 
amount,  and,  if  still  unsatisfied,  to  increase  the  strength  slightly  every 
second  day  to  the  desired  amount.  The  interval  allows  time  to  judge 
of  the  stools.  One  should  not  be  too  timid;  slight  disturbance  or  dis- 
comfort often  occurs  for  a  day  or  two  with  these  changes.  They  indicate 
that  we  must  stop  the  increase  for  the  time  being,  until  digestion  has 
adapted  itself  to  the  new  amounts,  not  necessarily  a  reduction  of  the 
food.  Sharp  or  continued  and  increasing  disturbance  calls  for  a  radical 
cutting  down  of  the  food,  clearing  out  the  bowel,  and,  with  restored  diges- 
tion, a  gradual  resumption.  With  artificial  feeding,  begun  at  birth,  plain 
water  plus  lime-water  is  a  satisfactory  diluent  in  most  cases.  If  cereal 
diluents  are  used  they  should  not  be  strong  (1  teaspoonful  barley  flour 
to  1  pint),  and  should  be  dextrinized.  Unless  cereals  have  already  been 
begun  they  are  a  useful  addition  about  the  eighth  month,  and  need  not 
then  necessarily  be  dextrinized,  since  it  is  better  that  the  digestion 
should  perform  its  own  work  if  possible.  For  the  same  reason  alkaline 
additions  may  be  omitted  at  this  time  if  practicable,  as  recent  experi- 
ments in  feeding  young  animals  would  seem  to  indicate  that  too  long 
continuance  of  alkalies  and  antacids  may  have  a  deleterious  influence 
upon  development.  This  raises  the  question  whether  the  tendency  on 
the  part  of  those  who  advocate  alkaline  diluents  during  the  first  year 
to  postpone  the  giving  of  many  articles  of  solid  food  until  later  periods 
than  formerly,  may  not  be  due  to  the  fact  that  under  this  system  the 
normal  development  of  gastric  digestion  has  been  delayed.  Food 
subserves  the  two  purposes  of  nourishing  the  body  and  furnishing  fuel 
to  maintain  body  heat.  Any  excess  of  heat  formed  must  be  given  off, 
and  this  heat  excretion  is  more  difficult  in  summer.  During  hot  weather 
less  fat  is  required  for  heat  production  than  in  cold,  and  less  can  be 
assimilated.  Fat  percentages  which  are  readily  taken  in  winter  often 
cloy  in  summer  and  cause  loss  of  appetite  or  even  actual  disturbance, 
while  the  body  will  also  be  as  well  nourished  with  a  smaller  amount  of 
food.  Much  subsequent  difficulty  will  be  avoided  if,  on  the  occurrence 
of  fever  or  any  acute  illness,  the  food  is  at  once  diluted  with  one-third 
to  one-half  plain  water,  as  digestion  is  always  temporarily  impaired. 


BEGINNING  MODIFIED  MILK  LATER  THAN  AT  BIRTH. 

In  the  case  of  all  artificially  fed  infants  who  come  under  our  super- 
vision at  any  period  later  than  at  birth,  it  is  advisable  to  investigate 
the  feeding  and  to  make  an  approximate  calculation  of  the  percentages 
which  the  child  is  receiving,  in  order  to  determine  whether  the  various 
elements  are  being  furnished  in  amounts  adapted  to  its  age  and 
needs.  This  is  especially  necessary  when  the  feeding  has  been  car- 
ried on  by  the  parents  or  friends.  Such  an  investigation  usually  reveals 
the  necessity  for  certain  radical  changes,  and  often  for  the  recasting 
of  much  of  the  regimen  if  future  trouble  is  to  be  avoided  and  proper 


148  I.M'WXT  FEEDING 

nutrition  maintained.  This  may  l)c  true  even  in  apparently  v. ell- 
nourished  children,  such  as  those  who  have  been  fed  on  condensed 
milk  or,  having  done  fairly  well  on  proprietary  foods,  have  been  kept 
on  them  too  long.  The  future  of  the  infant  demands  a  change,  but 
the  temptation  is  often  to  continue  while  the  infant  does  fairly  well. 
Good  judgment  is  required  in  these  cases.  In  the  case  of  an  infant 
who  has  just  begun  to  gain  and  to  show  a  better  digestion  after 
prolonged  disturbance  sudden  changes  should  not  be  lightly  made, 
but  the  necessary  elements  of  milk  should  be  introduced  or  gradually 
increased  to  replace  the  others  which  are  decreased  and  withdrawn. 
Young  infants  doing  well  upon  condensed  milk  may  be  carried  on  for 
a  time  by  the  addition  of  gravity  cream  (16  per  cent.)  in  a  quantity 
equal  to  that  of  the  condensed  milk  in  each  feeding.  This  may  then 
be  replaced  by  a  low  formula  in  which  the  fat  is  double  the  proteid. 
If  the  change  is  to  be  carried  out  at  once,  since  most  children  who  have 
been  fed  condensed  milk  have  received  mixtures  of  uncertain  strength, 
owino-  to  the  difliculty  in  estimating  the  actual  bulk  of  the  milk  added 
to  the  water,  and  since  at  best  these  contain  usually  low  fat  and  proteid 
percentages  with  a  relatively  high  sugar,  it  is  here  even  more  than  ever 
necessarv  to  follow  the  fundamental  rule  when  beginning  to  feed  modi- 
fications of  cows'  milk  to  any  infant  and  to  commence  invariably  with 
low  formuhe,  working  up  to  higher  ones.  This  rule  holds  good  in  all 
cases,  whether  it  be  in  giving  supplementary  feedings  to  an  infant  at 
the  breast,  or  in  weaning  a  nursed  infant,  or  beginning  the  feeding  of 
cows'  milk  either  at  birth  or  at  any  subserjuent  period  of  infancy.  It 
is  the  first  coiumandment  of  infant  feeding  and  the  second  is:  do  not 
continue  with  low  formuhv,  but  increase  the  fat  and  proteids  as  (juickly 
as  digestion  will  allow. 


ATTENTION  TO  DETAIL  IN  INFANT  FEEDING. 

Thoughtful  attention  to  detail  is  a  prerequisite  of  success  in  almost 
every  process  and  business.  The  overlooking  or  slurring  of  a  single 
matter  may  vitiate  the  whole  result.  Eventual  mastery  of  the  situation 
is  often  reached  only  by  the  most  painstaking  inquiry,  investigation  and 
observation  and  by  insistence  that  no  possible  contrilnitory  factor  siiould 
go  unrighted.  Time  must  be  taken  to  secure  the  past  history  of  the 
infant,  to  write  out  clearly  the  directions  to  be  followed,  and  to  catechize 
mother  and  nurse  as  to  the  practical  application  of  such  directions. 
The  clearest  instructions  are  often  neglected  or  misunderstood.  When 
methods  have  been  once  put  into  use  it  is  best  to  insist  at  a  subsefjuent 
visit  upon  a  detailed  account  of  each  step  in  the  attendant's  own  words, 
as  important  errors  are  often  only  brought  to  light  by  this  means. 
Actual  inspection  of  the  materials  and  processes  may  be  necessary  to 
detect  some  serious  fauU.  Observation  of  the  infant  and  its  manage- 
ment frequently  reveals  much  which  requires  change.  The  symptoms 
which  most  deeply  impress  the  attendant  are  often  the  least  important. 


SUBSTITUTE   INFANT  FEEDING  149 

and  the  really  suggestive  ones  must  frequently  be  extracted  by  cross- 
questioning. 

Important  Adjuncts  to  Digestion. — There  are  other  matters  besides 
the  preparation  and  proportions  of  the  food  and  the  quantity,  inter- 
val, and  number  of  the  feedings  which,  when  thrown  into  the  right 
or  wrong  side  of  the  balance,  assist  or  defeat  our  purpose.  These  will 
be  referred  to  briefly  in  this  section,  as  they  are  elaborated  in  other  parts 
of  the  book.  After  each  feeding  every  infant's  mouth  should  be  washed 
with  boiled  water  or  boric  acid  solution.  The  functions  of  the  skin 
should  be  maintained  by  the  daily  bath.  Normal  crying,  which  develops 
the  lungs  and  thus  favors  oxygenation  and  muscular  action,  should  be 
sought  rather  than  repressed.  After  feeding,  the  infant  should  be  laid 
down.  It  should  not  be  picked  up  because  it  cries,  but  a  change  of 
position  often  makes  it  comfortable.  Walking,  patting,  rocking,  and 
bouncing  an  infant  are  to  be  denounced.  They  do  not  relieve  pain, 
but  further  tire  out  the  nervous  system.  Abundant  sleep  at  regular 
hours  should  be  encouraged.  Amusements  and  numerous  or  compli- 
cated toys  should  not  be  forced  upon  the  infant's  attention.  With 
reasonably  free  play  for  the  exercise  of  legs  and  arms,  the  infant  should 
be  allowed  to  lead  a  vegetative  existence.  The  every-day  marvels  of  its 
environment  and  an  occasional  simple  toy  of  the  plainest  kind  furnish 
all  the  stimuli  which  are  advisable.  Undue  stimulation  of  the  nervous 
centres  is  usually  at  the  direct  expense  of  the  organs  of  digestion. 

Oxygen  in  Fresh  Air  as  a  Food. — In  discussing  the  composition  of 
food  no  thought  is  usually  given  to  that  most  important  element  which 
enters  the  body  not  by  the  mouth,  but  by  the  lungs.  A  large  proportion 
of  the  nutrition  and  tissue  change,  together  with  the  production  of  heat 
and  energy,  is  dependent  upon  the  combination  of  the  other  elements 
with  oxygen,  of  which  the  supply  must  be  continuous.  The  daily 
feedings  of  other  food  rarely  exceed  ten;  so  great,  however,  is  the 
demand  for  oxygen  that  this  must  be  supplied  to  the  infant  from  twenty- 
five  to  thirty-five  times- each  minute.  This  form  of  statement  will  serve 
to  emphasize  the  immense  importance  of  fresh  air,  which  must  be 
secured,  not  only  by  more  than  ordinary  attention  to  the  ventilation 
of  the  apartment,  but  by  taking  the  infant  into  the  open  air  as  early  and 
as  much  as  the  season  and  the  weather  allow\  In  inclement  weather,  at 
least  once  a  day,  the  infant  should  be  dressed  as  for  going  out-of-doors 
and  all  the  windows  of  the  room  thrown  wide  open.  By  attention  to  this 
one  factor,  failure  is  often  turned  into  success. 


COMMON  COMPLICATIONS  IN  INFANT  FEEDING. 

Vomiting. — This  may  be  acute  or  more  or  less  persistent. 

Acute  Vomiting. — When  not  an  initial  symptom  of  some  acute  disease, 
vomiting  is  either  due  to  the  food  itself  or  to  some  factor  which  tempo- 
rarily arrests  or  disturbs  the  process  of  digestion.  These  are  not  always 
distinguishable.     When  an  infant  otherwise  apparently  well  vomits  its 


150  IXFAXT  FEEDING 

food  the  rule  is  to  omit  the  next  bottle  entirely  or  give  in  its  place  plain 
water  and  to  dilute  the  followinii;  one  one-half  with  boiled  water.  If 
the  vomiting  is  repeated  or  there  have  been  from  the  first  other  symptoms 
of  disturbance  it  is  wise  to  sweep  any  remains  of  undigested  food  from 
the  stomach  and  l)owels  with  minute  doses  of  calomel  (O.OOOo  gm.  [gr.  y  y] 
for  five  to  ten  doses)  and  to  give  barley-water,  egg-water,  whey,  or  plain 
water  for  twelve  or  more  lK)urs  until  the  stomach  regains  its  tone  and 
appetite  returns,  beginning,  then,  with  temporary  low  dilutions  of  the 
usual  food.  When  no  other  cause  can  be  discovered  in  hot  weather  it 
is  often  a  safe  rule  to  reject  the  remaining  supply  of  food  which  luis 
been  made  up  and  to  await  the  arrival  of  a  fresh  supply  of  milk  on  the 
morrow. 

Habitual  Vomiting. — More  or  less  habitual  rejection  of  larger  or 
smaller  quantities  at  varying  intervals  after  the  food  has  been  taken 
calls  for  careful  investigation,  both  of  the  food  and  of  the  plan  of  feeding. 
Babies  whose  food  comes  up  easily  should  be  laid  down  at  once  after 
feeding  with  as  little  movement  as  possible  and  care  taken  that  the 
abdominal  bands  are  not  too  tight.  Accurate  observation  of  the  time, 
amount,  and  appearance  or  odor  of  the  vomitus  should  be  insisted  upon. 
We  distinguish  for  practical  purposes  between  the  vomiting  of  the 
larger  part  or  the  whole  of  the  food  ingested  at  a  meal  and  the  spitting 
up  of  a  teaspoonful  or  two;  and  also  whether  these  occur  within  a  few 
minutes  after  the  food  is  taken  or  some  time  later.  Spitting  up  of  small 
quantities  may  occur  with  eructations  of  gas  or,  as  in  healthy  breast-fed 
infants,  be  due  to  the  rejection  of  an  excess  of  food  from  an  overfilled 
stomach  when  the  peristalsis  of  digestion  begins.  This  latter  form  occurs 
soon  after  the  meal  is  finished  and  the  food  is  but  slightly  changed.  It 
is  best  met  by  a  i-eduction  in  the  quantity  given.  To  be  differentiated 
from  this  is  the  spitting  up  or  vomiting  of  sour-smelling  fluid  or  curds 
which  takes  ])lace  after  digestion  is  under  way.  This  may  be  at  first 
of  smaller  or  larger  fjuantities,  but  there  is  a  tendency  for  the  amount 
to  increase  and  to  contain  mucus  from  the  stomach.  This  is  very 
commonly  due  to  too  much  fat  in  the  food  and  is  best  treated  by  a  sharp 
reduction  in  the  fat  percentage.  In  other  cases  too  much  sugar  may 
be  productive  of  the  same  difficulty  and  this  must  be  lessened  in  amount. 
Spitting  up  and  vomiting  should  always  receive  immediate  attention  and 
not  be  allowed  to  continue,  for  not  only  has  the  habit,  when  once  estab- 
lished, a  tendency  to  continue  or  return  upon  slight  provocation,  but 
the  underlying  causes  soon  lead  to  disturbances  of  the  gastric  mucosa, 
as  evidenced  by  the  increased  secretion  of  mucus.  Having  corrected 
any  discoverable  faults,  one  or  two  teaspoonfuls  of  lime-water  given 
shortly  before  each  feeding  is  a  helpful  measure.  This  is  rather  more 
effective  than  increasing  the  amoimt  of  lime-water  in  the  food,  although 
where  it  already  enters  into  its  com])osition  it  may  be  raised  temporarily 
from  0  per  cent,  to  10  per  cent. 

Habitual  Constipation. — An  infant's  bowels  should  move  at  least 
once  daily.  When  this  is  not  the  case,  the  infant  is  liable  to  be  uncom- 
fortable, restless,  and  to  sleep  badly,  even  if  it  does  not  present  worse 


SUBSTITUTE  INFANT  FEEDING  151 

symptoms  of  colic  and  flatulence,  and  measures  should  be  taken  for 
its  relief.  Constipation  is  the  rule  with  infants  fed  upon  condensed 
milk  which  is  seriously  deficient  in  fat,  and  it  may  occur  in  those  given 
modifications  of  cows'  milk  containing  low  percentages,  and  is  over- 
come by  increasing  the  percentages  of  fat  if  they  are  below  the  usual 
schedule  averages.  Care  should  be  exercised,  however,  not  to  go  to  the 
other  extreme  and  exceed  the  amount  of  fat  which  the  infant  can  care 
for  without  disturbance.  But  few  infants  can  take  more  than  4  per  cent, 
fat  without  trouble.  It  has  only  recently  been  recognized  that  there 
is  also  a  form  of  constipation  with  dry,  hard  stools  due  to  excessive 
fat  in  the  food.  If  the  milk  has  been  sterilized,  changing  to  pasteurized 
milk,  or,  better,  if  a  pure  fresh  article  can  be  secured,  to  an  unheated 
milk,  may  solve  the  difficulty.  Proteids  in  excess,  especially  with  low 
fat,  may  give  rise  to  hard,  dryfeces,  which, when  broken,  show  a  granular 
surface  with  small  white  particles,  although  it  is  perhaps  more  common 
for  too  much  proteid  to  cause  loose,  undigested,  curdy  stools.  Decrease 
of  proteids  and  moderate  increase  of  fat  will  remedy  this  condition.  On 
the  whole,  however,  relief  of  constipation  is  most  commonly  achieved 
by  a  judicious  increase  of  both  fat  and  proteids,  which  increase  the 
unconsumed  residue.  Constipation  should  be  regarded  as  a  condition 
or  a  symptom  rather  than  a  disease,  and  is  due  most  commonly  to  diet, 
lack  of  proper  training,  or  to  muscular  inefficiency.  Dietetic  measures 
should  always  be  given  a  fair  trial.  Even  young  infants  can  be  trained 
to  have  their  stools  at  regular  times.  Gluten  suppositories  or  an  occa- 
sional small  and  simple  enema  are  far  preferable  to  the  habitual  use  of 
laxatives. 

Colic. — This  term  is  often  applied  loosely  by  parents  to  any  condition 
which  causes  the  infant  to  cry  and  draw  its  feet  up  toward  the 
abdomen.  It  may  arise  from  insuflicient  protection  of  the  abdomen 
and  extremities  from  cold,  but  is  chiefly  caused  by  indigestion  due  to 
excessive  proteids  and  is  accompanied  by  flatulence.  It  is  relieved  by 
heat  to  the  abdomen  and  extremities  and  stimulant  aromatics  like  dilute 
warm  peppermint- water;  a  small  enema  is  frequently  effective.  These 
tend  to  further  disturb  digestion,  if  given  frequently.  The  exciting  cause 
is  to  be  removed  and  the  condition  cured  by  the  reduction  of  the  amount 
of  proteid  (casein)  in  the  food,  or  by  measures  which  increase  its  digest- 
ibility. 

STOOLS. 

The  first  stools  of  the  newborn  infant  consist  of  dark-green 
meconium,  the  accumulated  secretions  of  the  intestinal  tract.  As  the 
flow  from  the  mother's  breasts  becomes  established,  the  meconium 
passed  in  the  first  days  is  replaced  by  bright,  orange-yellow  feces.  If 
the  milk  is  scanty  this  may  be  divided  into  small,  yellow  masses  or 
flakes,  surrounded  by  green  mucus.  These  small,  fatty  masses  are  often 
miscalled  curds  and  much  misunderstanding  thereby  arises.  True,  hard 
curds  are  not  formed  from  breast  milk.    In  all  c|uestions  of  insufficiency 


152  IXFAXT  FEEDISG 

of  l)rea.st  milk  and  wliere  disturliod  stools  are  reported  in  nursing  or 
bottle-fed  infants  tiie  physician  should  insistupon  having  the  napkins  kept 
for  his  inspection  and  learn  to  distinguish  the  dift'crent  types  and  their 
significance,  "^rhus  we  distinguisli  x\w  lighter  green  stools  of  indigestion 
from  the  small  and  frecpient  dark-green,  mucoid  stools  which  show  little 
or  no  milk  residue  and  intlicate  reduced  intake  from  whatever  cause. 
If  the  residue  of  breast  milk  be  bright  yellow,  it  is  not  a  question  of 
indigestion,  and  with  increased  ingestion  of  breast  milk  the  green 
bilivenhn  coloring  the  nmcus  will,  when  mixed  with  more  residue, 
appear  in  the  form  of  the  normal,  yellow  bilirubin  of  the  bile.  The 
absence  of  residue  in  the  stools  of  bottle-fed  infants  should  always  lead 
to  an  investigation  of  the  amounts  which  they  are  actually  taking  or 
retaining,  although  the  stools  are  not  as  typical  as  in  the  nursing  infant. 
What  has  been  said  of  this  characteristic  type  of  stools  should  not  be 
misapplied  to  other  types  of  green  stools. 

The  normal  stools  of  infants  receiving  cows'  milk  are  yellow,  l)ut 
have  not  the  orange  tint  of  the  breast  fed.  When  other  substances 
are  added  to  the  diet  the  color  is  often  influenced.  Certain  infant 
foods,  especially  when  given  unmixed  with  milk,  give  their  own  char- 
acteristic stools.  Imperial  (jranum,  Malted  Milk,  and  foods  of  the 
latter  class  give  dark  or  brownish  stools.  Barley-water,  given  alone, 
produces  a  somewhat  slimy  stool,  often  mistaken  for  mucus,  especially 
when  the  movement  shows  mucilaginous  particles. 

The  disturbed  stools  of  artificially  fed  infants  appear  in  very  varied 
and  frequently  mixed  forms,  but  certain  of  the-  types  may  be  men- 
tioned. 

In  normal  stools  it  should  be  possil)le  to  spread  the  fecal  matter 
out  by  pressure  with  the  naj)kin,  as  a  smooth,  homogeneous,  buttery 
mass.  Too  much  proteid  may  either  produce  constipation  or  diar- 
rhea. If  constipation,  the  stools,  especially  when  the  fat  is  low,  are 
friaVile,  and  when  broken  appear  to  Ije  made  up  of  small,  whitish 
granules.  I^oose  stools,  in  which  the  milk  residue  is  whitish  and  in 
small  flakes  or  masses,  are  usually  denominated  curdy,  even  when  these 
smooth  out  readily  and  are  soluble  in  ether,  shov/ing  them  to  be  mainly 
fatty  masses,  although  the  condition  is  caused  usually  by  proteid  indi- 
gestion. 

True  curds  are  firmer,  and  the  most  typical  are  rounded,  tough 
masses,  yellow  on  the  surface  and  white  within,  somewhat  resembling 
grains  of  Indian  coin.  These  are  formed  in  the  stomach,  where  the 
coagulation  of  the  milk  takes  place,  by  the  shrinking  of  considerable 
masses  of  the  denser  products  of  paracasein  with  acids,  which  the 
stomach  fails  to  digest,  and  are  passed  on  into  the  intestine,  where  they 
cannot  i)e  disintegrated  and  act  as  disturbing  foreign  bodies.  They 
presuppose  a  relative  excess  of  acidity  in  the  stomach,  and  may  be 
brought  about  by  (a)  the  presence  of  lactic  or  other  acids  formed  in, 
but  not  secreted  by,  the  stomach;  (h)  lactic  acid  in  the  milk  which  has 
been  allowed  to  become  slightly  sour  either  before  or  after  modification; 
(c)  hypersecretion  of  hydrochloric  acid,  the  total  acids  present  forming 


SUBSTITUTE  INFANT  FEEDING  153 

under  favoring  circumstances  more  large  and  tough  curds  than  the 
stomach  can  digest.  These  formations  can  be  prevented  by  peptoni- 
zation, or  by  the  addition  of  alkahes  which  neutrahze  any  acid  in  the 
milk,  or  acids  which  may  be  present  in  the  stomach  when  the  milk  is 
ingested,  and  also  delay  or  prevent  the  action  of  rennet  and  of  the  hydro- 
chloric acid  subsecjuently  secreted.  Other  contributory  measures  are 
the  use  of  a  fresh  milk  kept  properly  cooled;  pasteiu'ization,  which  kills 
lactic-acid-forming  bacteria;  further  dilution  of  the  milk;  and  the  use  of 
gruels  as  mechanical  attenuants  of  the  curd. 

Green  Stools. — No  very  satisfactory  explanation  of  the  green  stool  has 
been  advanced.  The  color  is  due  to  the  changing  of  bilirubin  to  bili- 
verdin  in  the  intestine  under  disturbed  conditions.  A  sharp  distinction 
in  prognostic  value  should  be  made  between  a  fairly  well-digested 
yellow  movement,  which  turns  green  on  the  surface  cpickly  on  exposure 
to  the  air,  even  before  the  diaper  is  removed,  and  the  all  green  or  green 
and  wdiite  stools.  The  former  (yellow  tiu'ning  green)  are  much  more 
favorable.  Stools  produced  by  calomel  are  often  green,  this  color  dis- 
appearing as  soon  as  the  action  of  the  drug  is  at  an  end.  Green  stools 
often  occur  in  epidemic  or  endemic  form  in  wards  of  institutions  caring 
for  bottle-fed  infants,  and  they  are  probably  due  to  infection  by  special 
bacteria.  The  same  probably  is  true  of  the  green  stools  of  summer 
diarrhea  which  are  of  protean  form. 

Fatty  Stools. — ^Excessive  fat  in  the  food  may  cause  loose  stools,  which 
may  even  have  a  greasy  appearance,  or  large,  hard,  dry  stools.  More 
frequently  they  are  sour-smelling,  yellow,  greenish-yellow,  or  even  green 
stools,  having  the  curdled  appearance  of  scrambled  egg,  and  may,  if 
continued,  contain  mucus.  Excess  of  sugar  may  at  times  be  respon- 
sible for  a  similar  condition.  In  certain  cases,  where  the  intestinal 
digestion  and  absorption  are  at  fault,  large,  gray,  putty-colored  move- 
ments are  passed,  with  a  peculiar  odor,  which  is  often  ammoniacal. 
They  contain  an  excess  of  fat,  which  should  be  reduced  in  the  food,  and 
small  doses  of  sodium  phosphate  (0.325  to  0.650  gm.  [gr.  5  to  10]  t.  i.  d.) 
given  to  re-establish  proper  hepatic  secretion.  In  older  children,  upon 
a  somewhat  mixed  diet,  especially  in  those  showing  the  large  abdomen 
and  other  signs  of  rachitis,  the  odor  of  the  stools  is  often  very  foul, 
filling  the  room.  Restriction  of  the  diet  to  milk  alone,  and  the  use  of 
some  intestinal  disinfectant  such  as  salol,  gr.  1,  four  times  a  day,  will 
often  prove  effective. 

Mucous  Stools. — Mucus,  to  some  extent,  is  an  integral  part  of  all  fecal 
movements,  but,  when  thoroughly  incorporated,  does  not  appear  as 
such.  It  appears  in  excess  in  most  conditions  of  prolonged  irritation, 
whether  from  the  presence  of  hard,  fecal  masses  or  from  faidty  digestion 
of  the  intestinal  contents. 

Watery  Stools. — Thin,  loose  stools  of  a  yellow  color  are  seen  in  the 
diarrheas  of  summer.  Profuse,  watery  stools  containing  only  occa- 
sional flakes  of  mucus,  the  so-called  rice-water  stools,  characterize 
the  intense  form  of  intestinal  poisoning  by  toxins  of  bacterial  origin, 
which  constitutes  a  true  cholera  infantum. 


154  IXFA.XT  FEEDING 

Bloody  Stools. — Blood  may  appear  not  infrequently,  and  varies  eon- 
sideral)ly  in  its  import.  A  hard,  constipated  movement  may  he  streaked 
with  l)rio;lit  i)lo()d  from  a  small  tear  of  the  anal  mucous  membrane. 
Such  streaking  in  nursing  bahies  without  temperature  does  not  often 
recur  after  a  moderate  dose  of  castor  oil.  In  severer  intestinal  con- 
ditions— colitis,  ileocolitis,  and  certain  epidemics  due  to  bacteria  of  the 
Shiga  group — blood  is  perhaps  even  more  liable  to  appear  in  the  stools 
as  the  result  of  intense  congestion  of  the  mucosa  than  of  actual  ulcera- 
tion. Hemorrhoids  are  seldom  seen  in  infancy.  Small,  bleeding  polyps 
are  of  occasional  occurrence.  It  should  never  be  forgotten  that  small, 
frequent  stools  of  blood  and  mucus  only,  passed  with  straining,  point 
strongly  to  intussusception. 


FEEDING  IN  DIFFICULT  CASES. 

^Vhile  some  children  \\'\\\  thrive  upon  almost  any  kind  of  feeding, 
and  the  majority  of  the  others  upon  carefully  adjusted  fornuda'  of 
modified  cows'  milk,  there  still  remains  a  mixed  class  which  try  our 
knowledge  and  ingenuity  to  the  utmost.  A  few,  very  few,  indeed,  are 
disturbed  by  small  ((uantities  of  cows'  milk,  or  seem  to  be  unable  to 
digest  enough  to  enable  them  to  secure  proper  nutrition,  antl  these  are 
better  wet-nursed  if  practicable.  But  this  view  of  tlie  case  shoidd  not 
be  assumed  lightly  or  without  intelligent  trial,  since  the  vast  majority 
of  those  wlio  come  into  our  hands  in  this  apparent  condition  are  the 
wrecks  left  by  ignorant,  injudicious,  and  unscientific  attempts  at  feeding, 
which  have  so  deranged  their  digestions  that  formuhie  suited  to  a  normal 
infant  of  that  age  are  not  tolerated.  This  is  the  class  which  has  caused 
most  of  the  dissatisfaction  with  percentage  feeding,  because  the  stock 
formuhe  fail  in  the  majority  of  instances  when  applied  to  these  difficult 
cases.  The  more  dilferent  kinds  of  infant  foods  which  have  been  tried  in 
rapid  succession,  and  the  greater  the  actual  or  relative  loss  of  weight  the 
infant  has  sustained,  the  more  difficult  the  problem.  If  the  practitioner  will 
always  start  upon  the  principle  that  no  infant  whose  percentage  feeding 
is  begun  at  any  time  later  than  birth  will  be  lial)le  to  digest  the  formidjc 
laid  down  for  the  age  at  which  such  feeding  is  begun,  but  that  he  must 
start  with  a  weak  formula  which  can  be  brought  up  more  or  less  rapidly 
to  stronger  ones,  the  most  frequent  source  of  failure  will  be  avoided. 
Furthermore,  practically  all  infants  who  have  been  variously  fed  before 
coming  into  our  hands  had  best  be  considered  as  having  disturbed 
digestions,  which  must  be  restored  by  beginning  v/ith  easily  digested 
mixtures  before  higher  ones  can  be  attained  to.  A  full  history  should  be 
secured,  in  such  cases,  of  the  previous  attempts  at  feeding,  the  pro- 
portions of  the  ingrerlients,  the  quantities,  the  daily  number  of  bottles, 
the  intervals  employed,  and  of  the  behavior  of  the  infant  with  the  various 
foods ;  especially  with  reference  to  sleep,  and  to  the  occurrence  of  vomiting, 
colic,  and  the  appearance  and  frequency  of  the  stools.  By  such  means 
only  are  we  in  a  position  to  discover  the  unrlerlying  errors,  and  to  avoid 


SUBSTITUTE  INFANT  FEEDING  155 

continuing  or  duplicating  them.  Many  infants  are  declared  to  be  unable 
to  digest  cows'  milk  when  the  difficulty  has  depended  upon  too  high  fat, 
or  too  high  proteid,  or  too  much  of  both.  In  reality,  suitable  modifica- 
tions of  cows'  milk  give  the  best  results  in  the  vast  majority  of  cases. 
Our  first  care  must  be  to  restore  digestion.  To  that  end  the  quantity 
of  each  feeding  and  the  interval  between  feedings  must  be  carefully 
regulated.  If  the  infant  has  been  given  the  bottle  irregularly  or  every 
two  hours,  the  interval  should  be  increased  to  at  least  two  and  one-half 
hours ;  or  better,  every  three  hours,  especially  if  the  child  has  passed  the 
age  of  three  or  four  months.  Frequent  night  feedings  allow  no  period 
of  necessary  rest  to  the  digestive  organs. 

When  the  disturbance  is  recent  or  the  development  fair  the  quantity 
given  may  be  determined  by  the  age  (see  p.  142),  but  infants  vrho  are 
considerably  under  weight  are  in  danger  of  being  overfed  in  amount. 
One  often  sees  infants  of  five,  six,  or  more  months,  who  still  weigh  only 
about  seven  or  eight  pounds,  scarcely  more  than  their  birth  weight. 
These  should  neither  receive  the  cjuantity  laid  down  for  normal  infants 
of  their  months,  nor  the  smaller  amount  which  a  normal  infant  of  their 
weight  would  be  given  during  the  first  few  weeks  of  life.  The  stomach 
has  grown  somewhat  in  its  normal  capacity,  but  has  either  suffered 
dilatation  from  overfeeding  or  is  confronted  with  that  danger.  Over- 
filling will  often  defeat  the  expectations  from  careful  modification  of  the 
food.  A  mean  must  be  struck  between  the  age  and  weight,  and  experi- 
ence teaches  us  that  this  is,  for  such  an  infant,  from  three  to  four  ounces. 
Such  infants  are  often  ravenous,  having  secured  little  nourishment  from 
the  food  which  has  been  ingested,  but  has  not  been  assimilated.  When 
these  infants  are  placed  upon  low  formulae  and  reduced  quantities  their 
apparent  hunger  may  continue,  but  may  be  disregarded  until  indications 
appear  showing  that  better  digestion  is  established.  W'here  we  have 
reason  to  believe  that  the  previous  difficulties  with  the  digestion  of  milk 
have  arisen  from  too  strong  formula?  or  when  beginning  milk  feeding 
for  the  first  time,  we  should  always  begin  with  a  low  formula  or  a 
mixture  which  we  are  reasonably  sure  is  within  the  digestive  power 
of  the  infant.  These  infants  rarely  do  well  at  first  with  a  fat  percentage 
more  than  twice  that  of  the  proteids,  such  as  those  made  from  the  top 
half  of  the  bottle,  15  ounces,  or  an  8  per  cent,  top  milk:  fat,  1.00;  sugar, 
6.00;  proteids,  0.50;  or,  fat,  1.50;  sugar,  6.00;  proteids,  0.75.  Often 
similar  dilutions  of  a  6  per  cent,  top  milk  (20  ounces  from  bottle)  are 
better  to  begin  with:  fat,  0.75;  sugar,  6.00;  proteids,  0.50;  or  fat,  1.00; 
sugar,  6.00;  proteids,  0.66,  etc.  While  with  marasmic  infants  whose 
powers  of  absorbing  fat  are  notably  poor  and  in  vomiting  cases  dilutions 
of  plain  milk  at  first  succeed  the  best:  fat,  0.50;  sugar,  6.00;  proteids, 
0.50;  fat,  0.75;  sugar,  6.00;  proteids,  0.75,  etc.  These  cases  have  less 
trouble  with  the  sugar  than  with  the  other  elements,  and  it  should  never 
be  omitted  in  these  formulae.  Either  alkaline  diluents  or  plain  or 
dextrinized  barley-water  may  be  used.  But  the  latter  is  perhaps  more 
commonly  successful,  although  if  one  plan  fails  another  may  give  good 
results.    The  parents  should  be  made  to  understand  at  the  outset  that 


156  INFANT  FEEDING 

our  first  aim  is  to  establish  normal  digestion  of  low  formulae,  as  shown 
by  the  disappearance  of  vomiting  and  colic  and  by  the  return  of  the 
stools  to  a  more  normal  color  and  consistency.  To  this  end  a  regular 
inspection  of  the  stools  is  even  more  important  than  seeing  the  infant 
itself.  The  securing  of  an  immediate  gain  in  weight  does  not  compare 
in  importance  with  this  improvement  of  the  symptoms  and  stools;  and, 
although  systematic  weighing  should  be  carried  on  for  the  guidance  of 
the  physician,  too  much  anxiety  should  not  be  felt  over  a  stationary 
weight  or  even  the  further  loss  of  a  few  ounces  during  the  first  few  days 
of  the  adjustment  period,  provided  the  symptoms  of  digestion  are 
improving  with  less  restlessness,  less  flatulence,  more  gastric  tolerance, 
and  better  stools.  These  low  proteid  percentages  should  not  be  too 
long  continued.  It  is  as  serious  an  error  to  persist  too  long  in  the  use 
of  low  formuhv  as  it  is  to  begin  with  those  that  are  too  high.  Just  as 
soon  as  improvement  in  the  symptoms  is  manifest  the  strength  of  the 
food — i.e.,  the  amount  of  milk  or  top  milk  in  the  formula — should  be 
pushed  gradually  forward  and  in  due  time  a  gain  in  weiglit  will  be 
inaugurated,  rem(>mbering,  however,  that  it  is  a  golden  rule,  when  an 
infant  is  gaining  satisfactorily,  to  let  well  enough  alone  and  to  postpone 
changes  until  they  are  clearly  indicated.  It  requires  careful  judgment 
at  times  to  determine  whether  an  infant  requires  more  in  quantity  of 
the  same  formula  or  the  same  quantity  of  a  higher  formula.  The  stools 
may  here  be  our  best  indication.  If  despite  care  we  overstep  the  limits 
of  digestion,  or  there  is  disturbance  from  any  other  cause,  we  should  not 
hesitate  to  sharply  cut  down  the  strength  of  the  food,  which  may  be  again 
gradually  restored  as  conditions  improve,  'i'he  mistake  should  not  be 
made,  on  the  other  hand,  of  changing  the  food  too  often,  for  slight 
disturbances  do  not  always  indicate  a  change,  since  the  cause  of  the 
difficulty  may  be  found  upon  investigation  to  be  due  to  carelessness  in 
the  preparation  of  the  food,  to  dirty  or  cold  bottles,  or  to  disregard  of 
instructions  concerning  feeding.  The  successful  management  of  difficult 
cases  comes  partly  from  experience,  but  is  also  dependent  largely  upon 
the  amount  of  intelligent  study  and  careful  supervision  of  the  case. 
After  investigating  the  previous  management  of  the  infant,  we  should 
endeavor  to  form  a  definite  plan  of  action,  based  upon  the  information 
which  we  have  secured  and  the  apparent  indications;  and  this  plan 
should  be  fully  tested  i^efore  adopting  another.  The  plan  which  we  adopt 
may  be  one  that  may  have  been  tried  before,  stripped  of  its  gross  and 
palpable  errors,  or  it  may  be  an  entirely  different  one;  but  everything 
which  we  do  shoidd  have  a  distinct  reason  and  purpose;  not  with  the 
forlorn  hope  that  anything  which  is  different  may  hit  the  mark.  If 
any  one  plan  has  been  previously  tried  for  some  time  a  radical  change 
may  be  crowned  with  success.  This  is  especially  true  in  vomiting  cases. 
It  is  a  good  rule,  upon  assuming  the  care  of  a  new  case,  and  always 
when  beginning  a  new  line  of  feeding,  to  start  afresh  by  clearing  out 
the  bowels  with  calomel  or  castor  oil.  Sucking  nipples,  "pacifiers," 
or  "comforts"  are  frequent  appurtenances  of  these  cases,  and  should 
be  unqualifiedly  condemned  and  their  use  stopped.     They  overtax  the 


SUBSTITUTE  INFANT  FEEDING  157 

salivary  glands,  favor  the  continuance  of  vomiting,  are  unhygienic,  and 
introduce  dirt  and  bacteria  into  the  alimentary  tract  besides  inaugurating 
a  train  of  most  undesirable  habits.  Such  infants  must  be  under  close 
observation  for  a  time.  The  mother  should  understand  that  a  single 
food  prescription  will  not  dispose  of  the  matter.  Not  only  will  some 
changes  and  variations  probably  be  necessary  before  the  combination 
is  found  upon  which  the  infant  does  best;  but  once  found  this  cannot 
be  continued  indefinitely,  but  must  be  altered  from  time  to  time  as 
improved  digestion  and  assimilation  allow  us  to  do  so.  Many  of  these 
cases  fall  into  two  groups  in  which  the  symptoms  are  either  chiefly 
gastric  or  chiefly  intestinal.  The  former  have  as  their  prominent  symp- 
toms vomiting  or  habitual  spitting  up  of  their  food;  the  latter,  cohc, 
eructations  of  gas,  furred  tongue,  flatulent  distention  of  the  abdomen, 
constipation,  or  frequent  loose  stools  which  may  contain  mucus. 

Vomiting  Cases. — Vomiting  which  has  become  habitual  often  proves 
the  most  difficult  obstacle  to  overcome,  as  it  prevents  the  retention  of 
a  sufhcient  quantity  of  food.  If  the  disturbance  has  been  very  marked, 
it  may  be  wise  to  stop  all  other  food  and  rest  the  digestive  organs  by 
giving  only  dextrinized  barley-water  for  one  or  two  days,  and  then 
begin  by  adding  a  teaspoonful  of  milk  to  each  bottle,  promptly  increasing 
the  amount  added  as  it  is  tolerated.  Daily  lavage  of  the  stomach  for  a 
few  days  may  be  necessary  at  the  outset,  especially  where  there  is  much 
mucus.  In  some  of  the  worst  cases,  having  washed  the  stomach  once 
each  day,  the  food  must  be  given  at  all  the  feedings  by  the  stomach 
tube  and  funnel  (gavage)  and  will  only  be  retained  when  so  administered. 
It  is  important  to  pinch  the  tube  when  it  is  removed  and  withdraw  it 
quickly  so  that  no  food  will  be  deposited  in  the  pharynx  to  invoke 
gagging  and  vomiting.  Whey  is  often  well  borne  when  other  food  is 
vomited,  possibly  because  of  its  low  fat ;  but  its  use  alone  should  not  long 
be  continued.  Excess  of  fat  and  sugar  must  be  avoided,  but  the  necessity 
for  retaining  these,  especially  the  sugar,  to  some  extent  must  not  be 
forgotten  or  the  proteids  will  be  called  upon  to  furnish  body  heat. 
Many  of  the  artificial  foods,  which  contain  much  sugar  (soluble  carbo- 
hydrates), we  have  come  to  recognize  as  common  exciters  of  vomiting 
and  loose  stools  and  are  to  be  avoided  in  vomiting  cases.  Firm,  cheesy 
lumps  in  the  vomited  matter  call  for  increased  alkalinity  or  reduction 
of  the  proteids  or  also,  perhaps,  for  peptonization  of  the  food.  Dilu- 
tions of  plain  milk  are  the  best  to  begin  with.  The  interval  should  not 
be  less  than  three  hours  for  young  infants,  and  if  we  keep  the  fat  low 
smaller  quantities  of  a  more  concentrated  food  are  more  liable  to  be 
retained  than  larger  ones. 

Intestinal  Cases. — These,  as  stated  above,  are  usually  distinguished 
by  the  occurrence  of  colic  and  tympanites,  with  constipation  or  curdy, 
loose  movements.  These  types  almost  always  arise  primarily  from 
difficulty  with  the  digestion  of  the  proteids  or  more  specifically  of  the 
casein  of  cows'  milk,  which  calls  for  reduction  in  its  amount  or  measures 
which  will  add  to  its  digestibility.  Ordinarily  relief  is  best  effected  by 
further  dilution  of  the  milk,  allowing  the  stomach  to  perform  more 


158  L\FA\T  FEEDING 

thoroiifjhlv  its  part  in  dijjjc.stion  and  so  losseninfr  the  burden  fallintr  upon 
the  intestine.  To  be  elleetive,  as  in  all  changes  in  food  to  meet  special 
symptoms,  the  reduction  should  be  a  radical  one,  with  subsequent 
tr'radual  increase.  These  children  usually  digest  their  proteids  better 
in  the  presence  of  a  fat  percentage  twice  to  three  times  that  of  the 
proteids,  which  are  about  the  normal  proportions  in  breast  milk.  Lower- 
ing the  proteids  in  this  class  does  away  with  the  colic  and  flatulence  in 
constipated  cases  and  the  indigestion  w^hich  leads  to  diarrhea.  Increas- 
ing the  fat  relieves  constipation  in  the  former  group,  the  residue  of 
miabsorbed  fat  making  the  stools  softer.  Care  should  be  exercised, 
however,  not  to  overdo  this,  since  excessive  fat  will  disturb  the  stomach 
and  cause  regurgitation  or  vomiting,  or  may  be  too  laxative  and  cause 
loose  movements.  Few  if  any  infants  can  exceed  3  per  cent,  fat  during 
the  first  three  to  four  months,  or  4  per  cent,  fat  during  the  remainder 
of  the  first  vear,  without  trouble  ensuing  sooner  or  later. 


OTHER  MEANS  OF  INCREASING  THE  DIGESTIBILITY  AND 
ABSORPTION  OF  PROTEIDS. 

If  a  fair  trial  of  dilution  and  gradual  increase  of  proteids  fail 
to  relieve  the  symptoms  of  proteid  indigestion,  or  their  gradual 
increase  to  a  point  necessary  for  nutrition  be  followed  by  a  return  of 
the  diflBculty,  other  measures  may  be  adopted.  The  most  recent  is 
that  of  "split  proteids,"  or  the  employment  of  whey  as  part  of  the 
diluent  of  a  rich  top  milk,  so  that  with  a  suitable  amount  of  fat  there 
shall  be  but  a  small  amount  of  casein,  the  remainder  of  the  proteid 
recjuired  being  made  up  of  the  soluble  proteids  of  whey.  The  use  of 
dextrinized  barley-water,  which  furnishes  some  absorbable  vegetable 
proteid,  may  prove  especially  successful  in  the  intestinal  type  of  cases. 
Peptonization  may  also  serve  us,  although  less  effective  in  the  intestinal 
than  the  gastric  class.  'J^lie  influence  of  alkalies,  lime-water,  and  bicar- 
bonate of  soda,  in  preventing  tiie  formation  by  the  gastric  secretions  of 
denser  and  less  easily  digested  compounds,  should  also  be  kept  in  mind. 
Although  not  ordinarily  recommended  for  the  food  of  infants,  condensed 
milk,  begun  with  the  proportion  of  one  level  teaspoonful  to  four  ounces 
of  water,  will  fre(|uently  be  successful  when  other  efforts  fail.  It  shoidd, 
of  course,  be  increased,  and  in  due  time  changed  to  modified  milk. 
Favorable  results  are  more  readily  attained  in  private  practice,  even 
among  the  poor,  if  reasonable  co-operation  can  be  .secured  from  the 
parents,  than  in  large  institutions  where,  esjjecially  when  crowded  and 
the  air  space  j)er  infant  less  than  1  ()()()  to  1200  cubic  feet,  infants  under 
six  months  of  age  show  a  large  mortality.  One  important  factor,  at  least 
in  institutions,  is  probably  "crowd  poisoning,"  from  which  authorities 
on  militarv  matters  .state  that  even  soldiers  on  the  march  are  liable  to 
suffer,  although  in  the  open  air,  if  allowed  to  retain  close  formations. 
Some  of  the  worst  cases  of  malnutrition  will  not  thrive  on  usual  modifica- 
tions of  milk,  and  show  continuous  loss  of  weight  and  require  special 


SUBSTITUTE  INFANT  FEEDING  I59 

measures  to  stay  the  loss  and  re-establish  a  gain.  To  these,  especially 
if  there  be  vomiting,  whey  may  be  given  for  a  few  days,  but  it  must  no't 
be  continued  too  long  alone.  Better  still  is  whey  with  the  white  of 
one  fresh  egg  to  each  10  to  16  ounces,  strained  and  salted.  Important 
adjuncts  in  the  treatment  of  these  especially  difficult  cases  are  liquid 
peptonoids,  5ss-j,  with  each  feeding,  which  serves  more  to  stimulate 
absorption  than  to  furnish  nourishment.  Difficulty  in  proteid  digestion 
of  even  small  amounts  of  casein  is  often  assisted  by  elixir  lactopep- 
tine,  15  to  20  drops  in  each  bottle.  A  temporary  respite  from  loss 
of  weight  and  a  slight  gain  which  may  be  continued  by  careful  feed- 
ing are  sometimes  effected  by  protonuclein,  0.06-0.12  gm.  (gr.  1-2), 
four  times  a  day.  Once  started  upward,  these  malnutrites  must  be  most 
carefully  guarded  from  upsets.  Partial  breast  feeding  may  be  their  only 
salvation  in  institutions,  even  if  but  a  few  daily  nursings  can  be  secured. 
Normal  development  demands  proper  amounts  of  fat,  sugar,  and  proteids; 
but  children  whose  digestions  have  been  long  disturbed  vary  greatly  in  the 
amounts  of  each  which  they  can  properly  care  for;  so  that  while  our 
aim  is  to  get  the  elements  back  to  somewhere  near  usual  proportions, 
when  it  can  be  safely  done,  the  food  of  many  of  these  children  nnist 
differ  considerably  from  that  of  the  average  child.  With  digestion 
restored  and  a  proper  amount  of  food  for  their  individual  requirements, 
gain  in  weight,  although  often  long  delayed,  will  surely  come. 

PEPTONIZED  (PANCREATIZED)  MILK. 

Peptonization  has  two  purposes:  to  increase  the  digestibility  of  milk, 
and  to  increase  the  amount  of  its  casein  which  the  child  can  take  without 
disturbance.  The  usual  peptonizing  tubes  contain  5  grains  extractum 
pancreatis  and  15  grains  sodium  bicarbonate.  The  process,  therefore, 
is  analogous  to  intestinal  digestion  in  an  alkaline  medium.  It  is  chiefly 
useful  where  the  difficulty  is  gastric,  as  it  predigests  more  or  less  of  the 
casein,  transforming  it  into  non-coagulable  albumoses  and  peptones. 
But  whether  more  or  less  of  the  casein  is  transformed,  the  alkalinity 
of  the  bicarbonate  of  soda,  especially  if  it  has  been  heated,  restrains  the 
action  of  the  rennet  and  acid  of  the  stomach,  preventing  to  any  extent 
the  formation  with  the  remainder  of  tough  acid  paracasein  curds.  In 
short,  gastric  digestion  is  more  or  less  cut  out.  With  vomiting  cases 
the  fat  should  be  kept  low. 

It  is  also  useful,  though  less  frequently,  where  the  trouble  is  intestinal. 
The  degree  to  which  the  predigestion  of  the  casein  is  carried  depends 
upon  the  length  of  time  during  which  the  action  of  the  ferment  is  allowed 
to  continue.  Milk  may  then  be  partially  or  completely  peptonized. 
For  young  infants  the  time  should  be  rarely  less  than  twenty  to  thirty 
minutes  to  be  effective.  Heating  the  milk  to  the  boiling  point  kills  the 
ferment  and  stops  further  action.  Complete  peptonization  of  all  the 
casein  requires  about  two  hours  and  is  at  times  necessary.  All  the 
feedings  for  the  day  may  be  peptonized  in  bulk,  or,  what  is  often  better, 
a  small  portion  of  powder  may  be  added  to  the  warmed  bottle  a  definite 


IGO  IXFA.Wr   FEEDING 

time  hoforc  cacli  fordinij.  The  contents  of  oacli  peptonizino;  tube  is 
sufficient  to  transform  1  pint  (10  ounces)  of  milk.  In  peptonizing 
the  total  food  prepared  for  the  day,  if  the  mixture  contains  8  ounces 
of  milk  or  top  milk,  use  one-half  tube,  etc.  In  adding  to  the  bottle 
before  feeding,  use  a  little  more  than  one-sixteenth  of  the  tube  for  every 
ounce  of  whole  milk  or  top  milk  which  entered  into  the  pre{)arati()n  of 
the  bottle.  Following  this  plan  the  nurse  may  be  directed  to  divide  the 
contents  of  a  peptonizing  tube  into  a  specified  number  of  powders. 
Peptonizing  should  not  be  continued  indefinitely,  else  the  functions  of 
the  stomach  become  weakeneil  by  disuse.  As  soon  as  possil)le  it  should 
be  stopped  by  reducing  the  time  five  to  ten  minutes  each  day  until 
withdrawn.  Peptonization  is  probably  employed  less  frequently  than 
formerly,  as  it  is  often  disappointing  in  its  results  except  in  selected  cases, 
and  it  in  nowise  removes  tlie  necessity  for  intelligent  modifications.  Con- 
tinued for  more  than  fifteen  minutes  it  develops  a  slightly  bitter  taste, 
which  is  not,  however,  usually  objected  to  by  infants. 

Peptogenic  milk-powder  is  composed  of  pancreatin,  sodium  bicar- 
bonate, and  milk-sugar.  One  measure  or  capful  is  required  for  each  pint 
of  milk.  If  employcnl  for  young  infants  or  those  with  difficult  digestion, 
the  usual  mixtures  advised  are  too  strong  and  the  powder  should  be 
added  to  formuhx^  suited  for  the  case.  As  pepsin  always  contains 
rennet,  it  will,  if  added  to  milk,  curdle  it. 

WHEY  AND  CREAM  AND  WHEY  MIXTURES. 

I\Iany  infants  experience  so  nuich  (Hfficulty  in  digesting  the  casein 
of  cows'  milk  in  sufficient  quantity  to  maintain  nutrition  and  to  provide 
for  increase  of  weight,  that  the  attempt  has  been  recently  renewed  to 
increase  the  amount  of  easily  absorbable  proteid  in  the  food  by  the  use 
of  whey  v/hicli  contains  the  soluble  proteids  of  the  milk.  This  plan, 
which  is  especially  capable  of  variation  in  laboratory  heeding,  has  l)een 
called  that  of  "split  proteids,"  although  such  admixture  of  soluble 
proteids  and  casein  exists  in  all  milks  and  in  al!  modifications  of  milk. 
It  really  consists  in  increasing  the  amount  of  the  soluble  proteids  in  an 
infant's  food  without  increasing  in  the  usual  proportions  the  amount 
of  casein.  This  may  l)e  brought  about  by  using,  as  the  basis  of  the 
food,  whey,  in  which  the  soluble  proteids  of  the  milk  have  been  largely 
separated  from  the  casein  by  clotting  the  latter  with  rennet.  To  reduce 
this  to  a  scientific  basis  it  is  necessary  that  we  should  start  with  a  clear 
conception  of  the  composition  of  whey.  The  following  table  from 
Van  Slyke  gives  actual  analyses  of  whey  maile  from  poor,  medium,  and 
rich  milks. 

Whev. 

From  poor  From  meilium  From  rich 

milk  containing  milk  containing  milk  containing 

3  per  cent,  fat  4  per  cent  fat.  5i)er  cent.  fat. 

Total  solids 6  87  6.96  7.38 

Fat 0.28  0.30  0.30 

Total  proteids 0.69  0.87  1.03 

Sugar  and  ash 5.90  5.79  6.04 

Water 93.13  93.04  92.62 


SUBSTITUTE   INFANT  FEEDING  161 

From  this  we  may  deduce  that  whey,  such  as  is  made  in  cheese 
factories,  if  prepared  from  a  good  average  4  per  cent,  fat  m.ilk,  will 
contain  about  0.30  per  cent,  fat,  0.90  per  cent,  proteids,  5  per  cent,  sugar, 
and  0.75  per  cent,  mineral  salts.  Wheys  prepared  for  home  modification 
show  considerable  variation  in  their  constituent  percentages  owing  to  the 
different  milks  used,  the  different  preparations  of  rennet,  and  the  method 
employed  in  making  the  whey.  Ordinary  methods  give  a  very  cloudy 
whey.  This  cloudiness  is  due  to  finely  divided  particles  of  the  junket 
clot  (paracasein)  and  more  or  less  fat.  Whey  made  from  whole  milk 
will  contain  more  fat  than  that  made  from  a  milk  from  which  the  cream 
has  been  largely  removed.  The  following  method  is  recommended  for 
securing  a  fairly  fat-free  whey  or  for  making  cream  and  whey  mixtures : 

Method  of  Making  Cream  and  Whey  Mixtures. — Secure  a  quart  bottle 
of  good  average  milk  upon  which  the  cream  has  risen.  Remove  with 
the  Chapin  dipper  the  upper  5  ounces  of  the  cream  layer,  which,  when 
mixed,  v/ill  contain  about  20  per  cent,  of  fat,  and  preserve  this  for  further 
use.  Pour  the  remainder  of  the  bottle  (about  27  ounces)  into  a  double 
boiler,  the  lower  portion  of  which  contains  tepid  water,  and  add  one 
tablespoonful  Shinn's  liquid  rennet,  or  one  Hansen's  junket  tablet,  or 
one  tablespoonful  of  Wyeth's  liquid  rennet.  Mix  thoroughly.  Place  a 
chemical  thermometer  in  the  whey,  and  heat  slowly  up  to  155°  F.  (68°  C.) 
to  destroy  the  rennet  ferment,  which  otherwise  would  clot  the  casein  of 
the  cream  or  top  milk  when  subsequently  added  to  the  whey.  Heated 
beyond  155°  F.  the  albumin,  part  of  the  soluble  proteids,  will  be  coagu- 
lated and  the  nutritive  value  of  the  whey  reduced.  As  soon  as  a  solid 
curd  forms  cut  this  crosswise  into  small  pieces  with  a  table  knife  to  facili- 
tate the  escape  of  the  whey,  and  while  continuing  to  heat  to  155°  F.  use 
the  flat  of  the  knife  blade  to  assemble  and  press  together  the  pieces  of  curd. 
This  increases  materially  the  yield  of  whey,  and  the  curd  finally  contracts 
with  heat  and  manipulation  into  a  rubbery  lump  the  size  of  the  palm 
of  the  hand.  Straining  through  a  wire  strainer  now  gives  20  ounces  or 
more  of  moderately  opaque  yellowish  whey,  upon  which  but  little  fat  rises 
on  standing.  Adding  to  20  ounces  of  this  whey  varying  amounts  of  the  top 
5  ounces  of  cream  (20  per  cent,  fat),  previously  removed,  will  give  us  a 
series  of  formula  suitable  for  most  purposes  where  cream  and  whey  mix- 
tures are  required.  By  removing  and  using  the  top  6  ounces  (17  per  cent, 
fat)  or  top  7  ounces  (15  per  cent,  fat),  mixtures  may  be  obtained  with 
a  lower  fat  percentage ;  or  by  using  more  of  these  top  milks  in  the  mixture 
the  same  amount  of  fat  with  a  larger  proportion  of  casein  in  the  proteids. 

Whey  and  Cream  Mixtures,  Made  from  20  Per  Cent.  Cream  (Top  Five  Ounces 

OF  One  Quart  Bottle)  and  Twenty  Ounces  of  Whey  from 

Remainder  of  Bottle. 

Fat 
percenta 
oz.  cream  (20  per  cent,  fat)  =  1.00 


20  oz 

whey  +  1 

20  " 

"      +  1>^ 

20  " 

"      +2 

20  " 

"      +2>^ 

20  " 

"      +  3 

20  " 

"      +3>^ 

20  " 

"      +4 

11 

Fat 
jrcentage. 

Sugar 
percentage. 

Proteid 
percentage 

=  1.00 

5.00 

0.90 

=  1.50 

5.00 

1.00 

=  2.00 

5.00 

1.10 

=  2.40 

5.00 

1.15 

=  2.75 

5.00 

1.20 

=  3.15 

5.00 

1.25 

=  3.50 

5.00 

1.30 

102 


INFANT  FEEDING 


Bartley  .suggests  the  addition  of  the  white  of  a  fresh  egg  and  also  of 
a  full  tables|)oonful  of  milk-sugar  dissolved  in  the  whey  of  eueli  quart 
bottle  of  milk. 

As  soon  as  digestion  is  re-estahli,shed  upon  a  whey  diet  a  eautious 
attempt  should  be  made  to  add  to  the  eream  and  whey  mixture  plain 
milk  or  a  larger  bulk  of  top  milk  with  a  lower  fat  eontent,  in  order  that 
the  .stomach  may  again  resume  its  function  of  digesting  casein,  which 
alone  supplies  the  form  of  proteid  recpiired  for  well-rounded  develoj> 
men.  Whey  feeding  at  best  should  be  but  a  temporary  ex])e(lient, 
unless  it  is  combined  not  only  with  extra  fat,  but  also  with  increasing 
quantities  of  casein  beyond  those  contained  in  the  formuUe  of  the  al)Ove 
table.  Although  invaluable  for  short  periods  in  certain  emergencies, 
the  continued  use  of  whey  alone  for  long  periods  is  disastrous  if  not 
indirectly  fatal  to  the  infant. 


CONDENSED  MILK. 

This  is  cows'  milk  from  which  a  large  part  of  the  water  has  been 
removed  by  evaporation  in  vacuum  pans,  in  Avhich  boiling  takes 
place  at  a  lower  temperature  than  under  ordinary  conditions.  As 
a  })art  of  the  process  it  is  also  sterilized.  It  may  then  be  sold  in 
bulk  for  immediate  use,  or  sealed  in  cans  with  the  addition  of  sugar. 
INIore  commonly  cane-sugar  is  added  as  a  preservative  in  propor- 
tion of  about  six  ounces  to  the  pint  of  condensed  milk.  Many  of  the 
so-called  evaporated  creams  are  no  richer  in  fat  than  average  condensed 
milk.  There  is  no  uniformity  between  the  various  l)rands  of  conden.sed 
milk  found  in  the  market.  Illinois,  New  York,  Ohio,  and  Oregon  alone 
have  laws  regulating  the  cjuality.  Elsewhere  brands  are  .sold  which 
analvses  show  to  be  evidently  made  from  .skimmed  milk.  The  ft^llowing 
table,  founded  u]K)n  an  analysis  of  "  Kagle  Brand,"  is  fairly  tyj)ical, 
furnished  to  Chapin  by  the  United  States  Department  of  Agriculture: 


With  15 

With  13 

With  11 

With  9 

With  7 

Cows'  milk 

Condensed 

parts 

parts 

parts 

parts 

imrts 

for 

milk 

water 

water 

water 

water 

water 

comparison 

per  cent. 

1  to  16 

1  to  14 

1  to  12 

1  to  10 

1  to  8 

per  cent. 

per  cent. 

per  cent. 

per  cent. 

per  cent. 

per  cen 

4.00 

Fat         ...      S.44 

0.53 

0.60 

0.70 

0.84 

1.05 

3.50 

Proteid  .        .        .      7.23 

0.45 

0.52 

0  60 

0.72 

090 

5.00 

„          f  cane,  41.52 )  ^ 
^"S^'-i  milk,  11.69/ ^=^-21 

3.33 

3.80 

4.13 

5.32 

6.65 

0.70 

Salts       .        .        .1.80 

0.11 

0.13 

0.15 

O.IS 

0.22 

86.80 

Water     .        .        .    28.41 

95.58 

91.95 

91.12 

02.91 

91.18 

Comparing  this  v.ith  average  percentages  of  fresh  cows'  milk,  it  will 
be  .seen  that  Leeds'  estimate  that  one  part  of  conden.sed  milk  ef|uals 
about  two  and  one-half  parts  of  fresh  milk  is  approximately  correct. 
It  will  also  be  evident  that  when  chluted  with  12  to  10  parts  of  water, 
according  to  the  usual  directions,  both  fat  and  proteids  are  very  low. 
But  the.se  directions  are  only  exceptionally  followed  by  the  laity,  who 
more  commonly  put  a  part  or  the  whole  of  a  teaspoonful  of  condensed 


SUBSTITUTE  IXFAXT  FEEDIXG  1(33 

milk  in  a  "cupful"  of  water  or  even  in  the  usual  S-ounce  feeding  bottle. 
This  would  give  dilutions  of  anywhere  from  1 :  32  to  1 :  64  if  a  teaspoonful 
of  condensed  milk  were  one  fluidrachm;  but  this  is  far  from  the  case, 
the  -^dscidity  of  the  milk  causing  it  to  adhere  to  the  entire  surface  of  the 
spoon  bowl  in  large  mass.  It  is,  therefore,  very  difficult  to  estimate 
the  amount  used  when  so  measured,  since  the  quantity  taken  up  depends 
upon  the  individual  and  upon  how  c(uickly  tlie  teaspoon  is  transferred 
from  the  can  to  the  water  before  part  of  the  viscid  mass  slowly  drops 
away.  The  bowl  of  the  teaspoon  plunged  into  the  can  and  immediately 
transferred  to  an  ounce  graduate  will  carry  with  it  anywhere  f-rom 
4  to  6  flnidrachms.  If  after  taking  up  the  milk  the  spoon  is  held 
over  the  can  from  two  to  three  minutes,  until  the  milk  practically  ceases 
to  drip,  the  amount  so  transferred  will  measure  foij.  This  last  method 
should  be  insisted  upon  when  accurate  proportions  are  desired. 

One  such  teaspoonful  to  each  4     oz.  of  water  (3ij  to  Sxssij)  gives  proportions  of  1  to  16 

"       "  "  "        Z]i  "         "  (oij  "  osxviij)     "  "  1   "  U 

"       "  "  "        3      "         "  (5ij  "   5xxiv)       "  "  1   "  12 

"  "        2>^  "         "  (3ij  "   5sx)  "  "  1  "  10 

"       "  "  "        2      "         '■  (oij  "   5xTJ)  "  "  1  "     8 

Boiled  water  should  always  be  used  in  preparation. 

Not  only  are  the  fat  and  proteids  lower  in  the  usual  dilutions  employed, 
but  the  fat,  even  in  the  best  brands,  is  too  low  for  continued  use  in 
feeding  healthy  infants;  wliile  the  proteids  also  cannot  be  raised  by 
less  dilution  to  the  point  required  for  nutrition  after  the  third  or  fourth 
month,  without  making  the  sugar  excessive.  In  a  word,  then,  condensed 
milk  and  water  cannot  be  made  to  furnish  suitable  proportions  of  tlie 
elements  for  proper  development.  If  its  use  be  long  continued,  although 
the  infant  may  appear  fat  from  the  assimilation  of  the  abundant  sugar, 
it  will  be  constipated,  flabby,  with  little  muscle  or  resistance  to  acute 
diseases,  and  will  invariably  show  more  or  less  evidence  of  rickets.  It 
owes  its  popularity  among  the  poor  to  its  cheapness  and  ease  of  prep- 
aration. Condensed  milk,  well  diluted,  often  serves  fairly  well  for  a 
short  time  with  very  young  infants  or  some  of  those  with  disturbed 
digestions  who  recjuire  low  fats  as  well  as  low  proteids,  while  easily 
digesting  sugar.  Being  sterile,  it  is  safer  than  other  milk  which  is 
obtainable  on  long  journeys,  or  in  summer  in  the  poorest  quarters  of 
some  iarge  cities;  but  a  change  should  always  be  made  as  soon  as 
possible  to  good,  fresh,  cows'  milk,  rememlDering  that  such  milk  should 
at  first  be  much  diluted.  (See  p.  148.)  When  the  use  of  condensed  milk 
is  imperative,  the  deficiency  in  fat,  which  is  its  worst  feature,  may  be 
made  up  by  adding  fresh  cream  or  giving  cod-liver  oil.  For  newborn 
infants,  and  those  of  difficult  digestion,  one  may  begin  with  a  dilution 
of  1:16  and  increase  the  strength  bv  less  dilution  to  1 :  10  or  1:8. 


ARTIFICIAL  FOODS. 

As  a  fundamental  axiom  it  may  be  stated  at  the  outset  that  no  artificial 
food  or  patented  food  can  take  the  place  of  breast  milk  or  properly 


1G4  IN  FA  XT  FEEDING 

proportioned  cows'  milk  for  any  consicU'rahk'  U'n<;th  ot"  time  williout 
injury  to  the  infant's  nutrition.  1  do  not  ^^o  as  far  as  some  and  say  that 
tiiey  should  never  be  used.  ]Many  of  them  have  a  place  in  emerf^encies, 
to  meet  certain  definite  conditions,  and  at  times  in  cases  of  difiicult 
feeding.  But  there  should  always  be  in  the  mind  of  the  physician  a  clear 
understanding  of  the  purpose  which  they  are  to  serve,  and  a  knowledge 
of  what  they  contain.  Nothing  is  more  fraught  with  disaster  to  the 
infant  than  a  trial  of  first  one  and  then  another  "infant  food"  in 
rapid  succession  in  the  blind  hope  that  some  one  will  succeed.  Com- 
mercialism leads  many  a  manufacturer  to  claim  for  his  particular  food 
the  credit  which  is  really  due  to  the  cows'  milk  with  which  it  is  diluted 
when  prepared.  Roughly  speaking,  "infant  foods"  are  (1)  preparations 
of  starchy  cereals  to  be  added  to  milk;  (2)  prepai-ations  of  soluble  carbo- 
hydrates (malt  and  other  sugars)  to  be  added  to  milk;  (3)  cereal  starches 
with  malt  and  other  sugars  mixeil  with  pulverized  condensed  milk. 
Without  the  addition  of  milk  neither  of  the  first  two  classes  furnish  the 
materials  for  full  nutritional  development.  I'he  latter  or  third  class 
cannot  l)e  made  to  contain  a  proper  amount  of  fat,  and  has  many  of 
the  disadvantages  common  to  condensed  milk.  Those  containing  malt- 
sugar  largely  are  laxatives,  and  while  we  may  often  avail  ourselves  of 
this  property  by  adding  them  to  the  food  of  constij)ate(l  infants,  the 
same  property  explains  the  loose  stools  occurring  at  times  in  infants  who 
are  given  this  type  of  food,  the  cause  of  which  is  often  unrecognized. 
While  these  sugars  are  at  times  better  assimilated  than  milk  or  cane- 
sugar,  and  cause  increase  of  weight  by  the  jiroduction  of  fat,  unless  the 
infant  foods  are  to  be  combined  with  a  suitable  amount  of  fresh  milk 
they  cannot  be  long  continued  without  danger  of  scurvy  and  rachitis, 
and,  still  more  insidious  because  perhaps  concealed  by  the  fat,  a  poverty 
of  muscular  tissue,  due  to  lack  of  sufiicient  proteid  material,  which 
renders  the  child  exceedingly  vulneral)le  to  any  intercurrent  disease. 
Some  of  those  most  used  in  this  country  are  a;;  follows: 

1.  Chiefly  unchamjed  starch.  Robinson's  Patent  Barley,  riubbell's 
Prepared  Wheat,  Ridge's  Food,  Imperial  Granum. 

2.  Containing  no  unchanged  starch,  hid  large  amounts  of  soluble 
car})ohi/dratcs.  (a)  T.argely  maltose— IMellin's  Food;  (/;)  Maltose  and 
other  soluble  carl)oliydrates  plus  evaporated  milk — Malted  Milk,  Cereal 
Milk;  (c)  Chiefly  lactose — Lactopreparata. 

3.  Containing  both  unchanged  and  changed  starch.  Carnrick's  Food: 
(a)  Plus  evaporated  milk — Nestle's  Food;  (6)  Largely  dextrose  and 
lactose — Eskay's  Food. 


MILK  LABORATORIES. 

In  many  of  our  large  cities  there  exist  to-(hiy  milk  laboratories  which 
undertake  to  fill  physicians'  prescriptions  for  the  feeding  of  any  par- 
ticular infant  and  to  deliver  each  day  the  requisite  number  of  bottles 
containing  the  amounts  and  proportions  ordered  by  the  physician,  ready 


SUBSTITUTE  INFANT  FEEDING 


165 


for  use  during  the  succeeding  twenty-four  hours.  The  milk  used  is 
derived  from  model  dairies  supervised  by  bacteriologists  and  veteri- 
narians, and  is  produced  as  nearly  as  possible  under  ideal  conditions 
for  the  purpose  for  which  it  is  to  be  employed,  every  care  being  exercised 
to  secure  a  clean,  fresh  milk  from  absolutely  healthy  cows.  The  labo- 
ratory does  not  prescribe;  it  simply  fills  the  physicians'  prescriptions 
with  the  best  obtainable  material,  with  the  nearest  possible  approach 
to  exactness  of  proportions  and  percentages,  and  with  studious  care  of 
each  step  in  its  preparation,  preservation,  and  subsequent  transportation. 
The  following  is  the  usual  form  of  prescription  blanks: 


Per  Cknt. 


Remarks. 


Milk-sugar 
Wlicyproteids 
Caseinogen 
Total  proteids 
Total  solids 
Water 


100  00 


Kumber  of  feedings 

Amoimt  at  each  feeding 

Infant's  age 

Infant's  weight 

Alkalinity. % 

Heat  at °  F. 


Ordered  for., 


.190 


Signature, 


While  at  first  planned  chiefly  to  secure  exactness  in  the  percentages 
of  modified  milk  and  in  the  quantities  furnished,  the  system  has  been 
developed  so  that  the  physician  may  indicate  and  secure  the  use  of 
either  centrifugal  or  gravity  cream;  alkaline,  cereal,  or  whey  diluents; 
milk-sugar  or  cane-sugar,  and  may  even,  if  desired,  include  the  addition  of 
proprietary  foods.  The  bottles  may  be  unheated,  pasteurized,  or  steril- 
ized, as  preferred.  The  necessary  calculation  of  the  required  proportions 
are  made  at  the  laboratory.  The  prescriptions  may  be  varied  within 
reasonable  limits  and  as  often  as  indicated  by  the  requirements  of  the 
infant.  It  has  the  great  advantage  of  exactness  and  ease  in  varying 
the  amount  of  any  particular  constituents  of  the  mixture,  some  combi- 
nations being  possible  which  cannot  be  secured  in  the  home,  and  it  is 
consequently  adapted  especially  for  the  management  of  cases  of  difficult 
digestion.  It  also  relieves  the  mother  and  attendants  from  all  respon- 
sibility and  labor  in  the  preparation  of  the  food,  and  the  physician  from 
giving  minute  directions  concerning  quantities  and  the  details  of  prepa- 
ration. On  the  other  hand,  it  presupposes  on  the  part  of  the  physician 
an   accurate   and   complete  knowledge  of  the   exact  percentages  and 


166 


INFANT  FEEDING 


constituents  of  the  food  \\lii(]i  will  he  best  adapted  to  the  ])artieular 
case  in  hand.  It  is,  therefore,  suited  es|)eeially  to  tlu>  uses  of  the  men 
already  well  trained  in  the  principles  of  infant  feeding,  and  has  heen 
employed  successfully  in  many  thousands  of  cases  when  intelligently 
directed  by  the  physician,  upon  whose  wisdoui,  in  the  main,  the  results 
depend.  Such  feeding  is  naturally  expensive,  costing  usually  thirty  ur 
more  cents  per  day,  and  is,  therefore,  available  ordinarily  only  for 
well-to-do  people.  The  objections  and  (lilii(  iiities  arising  from  this 
method  have  been  largely  due  to  unintelligent  use  of  its  facilities.  It 
is  not  to  be  expectoMl  that  every  child  will  do  best  upon  a  laboratory 
product.  There  are  some  failures  which  thrive  with  a  change  to  home 
modifications,  and  this  may  have  been  especially  true,  as  claimed,  when 
formerly  only  centrifugal  cream  was  used  in  laboratory  modifications; 
but  there  are  many  infants  with  whom  simply  a  change  of  method 
achieves  sviccess,  and  this  may  be  that  from  careless  home  modification 
to  careful  laboratory  feeding.  Much  of  the  ])resent  success  of  home 
modifications  is  due  to  the  pioneer  work  of  the  laboratories  in  the  pro- 
duction of  pure  milk  and  in  the  development  of  methods  of  modification. 

WEIGHING  AND  CHOICE  OF  SCALES. 

Much  important  information  concerning  the  progress  of  the  infant 
is  to  be  gained  from  systematic  use  of  properly  constructed  scales. 


Fig 

34 

MONTH  OF  AGE.                           j 

QMS. 

LBS. 

1 

2 

3 

4 

5 

« 

T 

8 

» 

10 

11 

12  1 

9530 
9070 
8020 
8100 
77.10 
72G0 
C800 
0350 
5900 
5440 
4990 
4540 
4080 
3030 
3180 
2720 
2270 

21 

20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 

G 

5 

/ 

/L 

/ 

^ 

^ 

^ 

■ 

1 

1 

L-- 

■^ 

^ 

^ 

^ 

' 

^ 

■^ 

y' 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

\ 

/ 

1 

Weight  chart.    (Holt.) 


Newborn  infants  and  difficult  feeding  cases  should  be  weighed  every 
second  day  or  twice  a  week  and  the  weights  recorded;  for  other  infants 
once  a  week  will  suffice.     While  gain  in  weight  does  not  invariably 


SUBSTITUTE  INFANT   FEEDING 


167 


Fig. 35 


indicate  well-rounded  nutrition,  as  in  infants  who  receive  the  high  sugar 
percentages  of  condensed  milk,  it  is  still  one  of  our  valuable  guides  as 
to  the  digestion  and  assimilation  of  the  food.  A  steady  gain  in  weight 
even  with  the  simpler  forms  of  "spitting  up"  the  food  or  moderate 
disturbance  of  the  stools  is  reassuring  and  shows  us  that  with  suitable 
changes  these  will  be  readily  overcome.  Failure  to  gain  in  the  absence 
of  any  disturbing  influence  and  with  good  stools  indicates  an  increase 
in  the  quality  or  strength  of  the  food.  On  the  other  hand,  stationary 
weight  or  a  loss,  with  disturbed  digestion  and  poor  stools,  may  call  for 
a  radical  reduction  until  digestion  is  re-established. 

The  chief  exception  to  this  latter  statement  is  in  children  who  have 
been  too  long  upon  very  low  percentages  which  do  not  furnish  sufficient 
nourishment,  but  such  cases  re- 
quire careful  investigation  and 
good  judgment.  The  usual  pro- 
gress of  a  normal,  healthy  infant  is 
best  indicated  by  the  accompanying 
weight  chart,  devised  by  Dr.  L.  E. 
Holt  (Fig.  34).  The  normal  infant 
should  show  on  the  average  a 
weekly  gain  of  not  less  than  four 
ounces  during  the  first  six  months; 
thereafter  it  may  be  somevi'hat  less. 
Infants  who  are  bottle-fed  from 
birth  often  begin  to  gain  more 
slowly  than  the  breast-fed,  but 
if    good    digestion    is    maintained 

should  later  regain  the  difference.  All  spring  and  dial  scales  are 
notoriously  unreliable  and  useless  to  record  small  variations.  To  give 
one  any  immediate  assistance  in  judging  of  the  effects  of  the  food 
prescribed,  upon  children  of  difficult  digestion,  the  scales  should  be 
of  the  balance  variety  and  register  half-ounces.  The  ordinary  grocer's 
scale  with  scoop,  or  scoop  and  platform,  can  now  be  obtained  cheaply 
enough  to  have  a  place  in  every  physician's  office  and  to  be  purchased 
by  parents  of  even  moderate  means  (Fig.  35).^ 


Scales  for  weighing  infants. 


FEEDING  AFTER  THE  FIRST  YEAR. 


Because  weaning  now  becomes  necessary  at  an  earlier  age  than  was 
formerly  the  case,  owing  to  the  failure  of  the  supply  of  breast  milk, 
especially  among  the  dwellers  in  large  towns  and  cities,  and  also  generally 
among  the  wealthier  classes,  no  ground  exists  for  assuming  that  the 
digestive  powers  of  the  infant  have  taken  on  correspondingly  earlier 
development.    It  is  an  unquestioned  fact  that  many  children  are  seriously 

1  A  reliable  scoop  and  platform  scale  of  this  pattern,  weighing  from  %  oz.  to  244  lbs.,  can  be  ob- 
tained from  the  Metropolitan  Hardware  Co.,  cor.  Church  and  Vesey  Streets,  New  York  City,  at  a  cost 
of  $3. 


168  IXFAXT   FEEDIXG 

handicapped  and  exposed  to  great  dangers  under  the  mistaken  idea 
tliat  this  period  is  the  proper  one  for  the  introchiction  into  the  child's 
dietary  of  general  table  food.  Second  only  to  the  revolution  in  the 
feeding  of  the  first  year  by  the  introduction  of  modified  milk  have  been 
the  rapid  changes  of  \dew  concerning  the  necessary  elements  of  the 
dietar}'  during  the  second  twelve  months.  ^Vith  respect  to  all  details 
pediatricians  are  by  no  means  fully  in  accord,  but  there  is  a  strong 
tendency  on  all  sides  to  simplify  the  diet  and  to  postpone  until  the  latter 
part  of  the  second  year  many  articles  which  were  formerly  given  earlier. 
Much  of  this  diversity  of  opinion  is  due  to  the  fact  that  children  at 
this  time,  almost  as  much  as  during  the  first  year,  differ  markedly  in 
their  digestive  abilities,  this  difTerence  being  due  to  previous  methods 
of  feeding,  environment,  etc.  Certain  principles  have,  however,  gained 
general  acceptance.  The  first  of  these  is  that  milk  is  not  to  be  abandoned 
or  even  allowed  to  become  of  secondary  importance,  but  continues  the 
basis  of  the  nourishment  until  at  least  the  middle  of  the  third  year. 
Where  the  infant's  digestion  of  proteids  allows  it  is  often  possible  and 
best  to  (jraduallv  brin^  it  about  that  at  the  twelfth  month  the  infant 
should  begin  to  take  plain  milk  without  modification  or  dilution,  save 
that  which  results  from  the  addition  of  cereal  jellies.  Not  all  infants 
can  do  this,  especially  those  whom  digestive  disturbances  force  us  to 
consider  and  treat  as  younger  than  their  actual  age  in  months.  Some 
of  these  must  receive  mo;lifications  of  milk  the  first  half  or  even  the 
whole  of  the  second  year.  The  increased  demand  for  proteids  at  this 
period  must  not  be  neglected;  and  if  they  cannot  be  taken  in  the  form 
of  milk  casein  the  deficiency  should  be  made  up  to  them  in  other  ways. 
While  the  danger  of  overfeeding  the  infant  at  this  time  more  commonly 
confronts  us,  we  occasionally  see  infants  who,  for  one  reason  or  another, 
are  continued  upon  weak  formulae  to  the  detriment  of  their  nutrition, 
which  imperatively  demands  different  and  more  varied  food.  The 
intelligent  physician  will  not  attempt  to  feed  all  children  alike  during 
.their  second  year,  any  more  than  he  would  so  feed  tliem  during  their 
first  year,  else  he  will  meet  with  frequent  failure.  The  age  in  months 
does  not  necessarily  furnish  any  exact  criterion  of  their  digestive  capabil- 
ities. Children  reach  their  second  year  differing  widely  in  th.eir  weight, 
robustness,  nutrition,  and  their  powers  of  digestion.  Some  have  been 
nursed  and  are  having  their  first  experience  with  other  food.  Others 
have  learned  to  digest  cows'  milk  months  earlier  or  even  from  their 
birth.  Some  have  been  brought  to  this  period  with  the  utmost  difficulty, 
and  the  exercise  of  the  greatest  intelligence  and  ingenuity  in  the  adapta- 
tion of  the  proportions  of  their  food.  Certain  children  of  a  year  old 
must  be  treated  as  though  they  were  many  months  younger.  The 
tissues  of  some  are  starved  for  the  proteids  which  they  have  been  unable 
to  assimilate  sufficiently  from  such  modifications  of  milk  as  they  could 
take  without  disturbance.  Still  others  are  prone  to  starchy  indigestion 
if  very  moderate  amounts  be  exceeded,  or  that  which  is  given  be  not 
most  carefully  chosen  and  prepared,  or  even  subjected  to  the  action  of 
ferments  which  alter  its  character.     It  is  with  this  knowled<;e  in  mind 


SUBSTITUTE  INFANT  FEEDING  169 

that  we  should  approach  the  question  of  feeding  the  individual  child 
during  the  second  year,  and  for  this  reason  it  is  difficult  to  lay  down 
hard-and-fast  rules  which  shall  not  be  subject  to  many  exceptions. 
This  explains  to  some  extent  the  diversity  among  the  diet  lists  of  our 
best  authors  for  this  period.  Coincident  with  the  demand  for  more 
proteid,  which  is  satisfied,  in  part  at  least,  by  the  giving  of  as  nearly  as 
possible  plain  milk,  occurs  a  decreased  need  of  sugar  as  such,  which 
from  now  on  the  body  is  prepared  to  make  for  itself  by  the  action  of 
the  salivary  and  pancreatic  secretions  upon  starch. 

Cereals. — Whether  we  allow  or  not  that  cereal  decoctions,  used  by 
many  during  the  first  year  of  life  as  diluents  for  cows'  milk,  undergo 
much  true  digestion  of  their  contained  starches  there  is  no  question 
but  that  by  the  beginning  of  the  second  year  the  amylolytic  or  starch 
digesting  functions  are  sufficiently  developed  to  demand  this  addition 
to  the  dietary.  Such  addition  is  best  in  the  form  of  thoroughly  cooked 
and  strained  oatmeal-,  barley-,  or  wheat-gruel,  the  thickness  of  this 
gruel  or  jelly  varying  inversely  with  the  amount  to  be  added  to  the  milk. 
Their  preparation  is  much  simplified  by  the  use  of  prepared  flours. 
If  the  grains  of  barley  or  oatmeal  are  used  they  should  be  cooked  no 
less  than  three  hours  to  soften  and  burst  the  cellulose  envelope  which 
surrounds  the  starch  grains.  Those  preparations  of  oatmeal  whose 
grains  have  already  been  subjected  to  rolling,  crushing,  or  steaming 
give  the  best  results,  although  requiring  much  the  same  amount  of 
cooking,  and  this  necessity  for  prolonged  boiling  of  all  the  cereals  con- 
tinues throughout  childhood.  After  cooking  they  should  be  strained 
to  remove  the  coarser  particles,  and  salted.  Thorough  cooking  and 
straining  add  much  to  the  digestibility  of  cereals,  and  where,  despite  this, 
there  is  still  difficulty,  it  may  be  often  overcome  by  the  addition  while  hot 
of  a  small  amount  of  a  glycerinated  solution  of  diastase  (cereo),  which 
transforms  some  or  all  of  the  starch  into  soluble  carbohydrates.  Barley 
flour  contains  less  starch,  and  is  more  easily  converted  into  sugar  by 
the  transforming  ferments  of  the  body,  and  may  be  chosen  when  these 
functions  are  less  developed  or  weakened.  It  is  to  be  chosen  when  there 
is  a  tendency  to  diarrhea.  Oatmeal  contains  more  fat,  starch,  and 
proteid;  so  that  it  is  more  nutritious  than  barley,  slightly  more  difficult 
of  digestion,  valuable  for  its  laxative  properties  in  constipation,  and  to 
be  avoided  in  diarrhea,  eczema,  and  intestinal  indigestion.  The  valuable 
properties  of  wheat  flour  have,  to  some  extent,  been  lost  sight  of,  except 
as  incorporated  in  special  preparations  or  used  as  the  basis  of  a  dextrin- 
ized  gruel.  It  is  more  commonly  used  in  the  form  of  stale  bread.  When 
cereals  are  eaten  by  themselves  the  most  suitable  are  oatmeal,  farina, 
wheatena,  hominy,  and  cornmeal ;  always  thoroughly  cooked  and  usually 
strained.  Of  these,  if  the  child  likes  it  and  it  agrees,  oatmeal  is  probably 
the  best  for  the  morning  meal.  Milk  or  equal  parts  of  milk  and  cream 
may  be  served  with  the  cereal,  which  should  be  properly  salted,  but  the 
use  of  sugar  should  be  prohibited.  Rice,  boiled  or  steamed  until  each  grain 
is  well  cooked,  may  be  given  alone,  or  served  as  an  addition  to  soups  and 
broths,  and  is,  perhaps,  more  suitable  for  the  midday  or  evening  meal. 


170  INFANT  FEEDING 

Bread. — Bread  should  always  be  stale  and  may  be  well  dried  also 
in  the  oven.  Broken  into  erunibs  it  may  be  given  moistened  with 
broth  or  beef-juice  or  mixed  with  soft-boiled  egg.  When  there  are 
sufficient  teeth  the  child  may  be  allowed  a  crust  to  nibble.  It  thus 
earns  to  chew,  and  the  secretion  of  the  salivary  glands  is  stimulated. 
Among  the  poor,  bread  is  given  early  to  children  and  constitutes  their 
introduction  to  starchy  food,  taking  the  place  of  cereals  combined  with 
milk.  Given  thus  in  moderation  it  fulfils  a  definite  role  and  is  beneficial, 
but  in  too  large  amounts  may  not  be  properly  digested.  "Bread  and 
milk"  has  a  time-honored  place  as  the  supper  of  somewhat  older  children, 
but  will  not  always  agree  as  well  as  when  taken  separately.  Zwieback, 
unsweetened,  is  one  of  the  best  forms  for  early  use,  and  is  often  retained 
and  digested  when  other  foods  fail.  Italian  bread-sticks  are  also  val- 
uable. Various  types  of  plain  unsweetened  crackers  (biscuit)  may  be  al- 
lowed later  for  variety;  and  gluten,  bran,  and  graham  crackers  when 
there  is  constipation.  These  latter,  however,  are  fn^cjuently  oversweet- 
ened  and  cause  fermentation.  Sweet  crackers  and  lady  fingers  often 
cause  disturbance  and  should  not  be  allowed  even  occasionally. 

Meat  and  its  Derivatives.— The  earliest  available  of  these  is  beef- 
juice,  the  red  juice  squeezed  fi-om  a  bit  of  round  steak  lightly  broiled 
on  both  sides.  This  has  its  strong  partisans  and  opponents,  and,  as  in 
most  such  matters,  there  is  a  rational  middle  ground.  It  is  useful  even 
toward  the  end  of  the  first  year,  especially  for  bottle-fed  children  whose 
proteid  percentages  have  necessarily  been  low  from  any  cause  or  who 
show  any  tendency  to  rachitic  or  scorbutic  changes.  It  is  a  blood 
builder  of  value  for  anemic  children,  and  is  a  tonic  stimulant.  It  should 
not,  however,  be  given  indiscriminately  to  all  children.  It  is  often 
better  withheld  from  the  children  of  nervous,  rheumatic,  or  gouty  parents, 
who  themselves  have  a  tendency  to  a  nervous  temperament  and  to 
strongly  acid  urine  of  high  specific  gravity  or  to  eczema  of  the  skin. 
These  are  often  better  without  it,  and  often  without  meat  or  soups. 
Some  deem  it  wise  to  give  finely  scraped  (not  minced)  pulp  of  rare  beef, 
one  to  three  teaspoon fuls,  where  others  would  use  beef-juice,  and  with 
good  reason,  since  it  contains  relatively  more  proteid  and  less  extractives. 
On  the  whole,  however,  there  is  a  tendency  to  reserve  meat  until  the 
latter  part  or  end  of  the  second  year,  when  the  presence  of  the  molar  teeth 
indicate  greater  readiness  for  food  which  requires  mastication.  Mutton, 
lamb,  beef,  and  white  meat  of  chicken  may  then  be  given  finely  minced, 
and  the  child  taught  to  chew  them  well  before  swallowing  them.  This 
they  may  not  do  without  watching  and  instruction.  Well-made  clear  soups 
and  broths  are  often  the  first  additions  after  the  cereal  jellies.  Mutton 
and  chicken  are  preferable  to  beef  for  broth,  although  an  occasional  use 
of  the  latter  will  give  variety.  They  should  be  thoroughly  freed  from 
fat  by  cooling,  which  enables  the  fat  which  arises  to  the  surface  to  be 
more  readily  removed.  Broths  may  be  introduced  into  the  dietary 
between  the  twelfth  and  fifteenth  months,  usually  at  the  midday  meal, 
and  should  be  clear,  except  possibly  for  the  addition  of  stale  bread- 
crumbs in  the  earlier  months  and  thorouglily  cooked  rice  in  the  later 


SUBSTITUTE   IXFAXT   FEEDING  171 

months  of  the  second  year.  AMien  the  family  history  or  symptomatic 
pecuharities  of  the  inchvidual  child  contraindicate  meat  products,  milk, 
soups — i.  e.,  thin  purees  of  peas,  beans,  cauliflower,  asparagus,  or 
celery — may  replace  those  made  of  meat  stock  which  contain  extractives 
in  considerable  amount. 

Eggs. — The  white  of  the  raw  egg  furnishes  a  readily  assimilable 
form  of  proteid,  which  is  often  useful  to  supplement  the  proteids  of  milk, 
and  even  for  short  periods  to  take  their  place  in  emergencies.  With 
racliitic  infants  the  white  of  one  egg  may  be  added  to  one  of  the  daily 
feedings.  Beaten  into  10  to  16  ounces  of  water  and  strained  with  the 
addition  of  salt  to  assist  osmosis  it  is  often  retained  where  other  food 
is  vomited,  and  furnishes  a  bland  food  in  acute  disturbances.  Although 
inferior  to  farinaceous  gruels  in  cases  of  summer  diarrhea,  it  may  be 
given  where  the  former  are  refused  by  the  child.  Soft-boiled  eggs  (two 
minutes)  are  usually  begun  at  some  time  during  the  second  year,  giving 
one-half  at  first.  They  should  be  rarely  given  oftener  than  on  alternate 
days,  as  children  tire  of  them  easily.  The  form  may  Ije  varied  by  mixing 
them  with  stale  bread-crumbs,  and  salt  may  be  added,  but  no  pepper 
or  butter.  The  yolk  of  the  egg  contains  tissue-building  material  of 
value,  including  10  per  cent,  of  lecithin,  which  enters  largely  into  the 
formation  of  the  nervous  system,  and  is  at  times  used  to  supply  the 
deficiency  of  lecithin  in  cows'  milk  as  compared  with  breast  milk.  For 
older  infants  poached  or  dropped  eggs  may  be  allowed  for  variety,  but  other 
forms  of  cooking  render  them  less  digestible  and  should  not  be  employed. 

Fruits  and  their  Juices. — Of  these,  strained  orange-juice  stands 
pre-eminent,  and  is  almost  a  necessary  part  of  the  diet  of  the  artificially 
fed  child  even  during  the  latter  part  of  the  first  year,  and  certainly 
during  the  second  year.  It  has  valuable  antiscorbutic  properties,  being 
a  specific  for  infantile  scurvy,  and  since  most  bottle-fed  children  have 
something  of  this  tendency  from  the  nature  of  their  food,  better  results 
are  obtained  by  its  routine  use  once  a  day.  It  is  also  a  valuable  laxative 
where  the  tendency  is  to  constipation.  In  the  third  year  the  pulp  may 
be  removed  and  given  with  a  spoon,  but  the  minute  sacs  which  contain 
the  juice  will  appear  in  the  stools  unless  the  envelope  be  broken  by 
chewing.  The  coarse,  white  fibre  should  not  be  allowed.  When  oranges 
are  not  obtainable,  the  juice  of  fresh  peaches  or  of  ripe  fresh  berries, 
strained,  may  be  cautiously  tried  as  a  substitute.  The  fruit  element 
may  also  be  supplied,  especially  where  there  is  constipation,  by  the  pulp 
of  two  or  three  prunes  cooked  without  sugar  and  passed  through  a  sieve. 
Thoroughly  cooked  apple-sauce  or,  even  better,  the  pulp  only  of  a  well- 
baked  apple  is  useful  toward  the  end  of  the  second  year.  Bananas, 
berries  v.-ith  their  seeds,  and  raw  apples  are  not  suitable  for  the  earlier 
years  of  childhood. 

DIET  FROM  TWELFTH  TO   FIFTEENTH  MONTH. 

During  this  period  the  child  should  receive  five  feedings  at  approx- 
imately the  following  hours,  according  to  the  convenience  of  the  house- 


172  IXFAXT  FEEDING 

hold:  First  feedino;,  G  to  7.30  a.m.;  socond  feeding-,  10. .'50  to  11  a.m.; 
third  fc>c(Hiii;',  1.30  to  2  P.M.;  fourth  fcodiiiti;,  o.oO  to  (>  p.m.;  fifth  feeding, 
9  to  10  P.M. 

From  10  to  12  ounces  may  be  given  in  the  bottle  at  each  feeding, 
and  this  may  consist  of  from  1  to  3  ounces  of  cereal  jelly  or  gruel  with 
the  remainder  plain  milk.  It  is  generally  accepted  that  an  infant  will 
drink  more  milk  from  the  bottle  than  from  a  glass  or  cup,  and  with  less 
efi'ort,  often  taking  from  10  to  14  ounces  when  it  woidd  be  difficult  to 
give  more  than  S  ounces  from  a  glass;  therefore,  it  is  well  to  be  in  no 
haste  to  give  up  the  bottle,  which  may  be  continued  until  the  middle  of 
the  year,  after  which  some  of  its  contents  taken  with  other  food  may  be 
poured  into  a  cup  in  order  that  the  child  may  learn  to  drink  in  that  way. 
The  late  evening  (9  to  10  p.m.)  l)ottle  may  be  continued  the  longest  or 
until  the  fifth  meal  is  abandoned. 

If  the  child  can  take  plain  milk  without  dilution,  this  may,  for  the 
sake  of  variety,  replace  the  milk  and  cereal  at  not  more  than  two  of 
the  meals,  especially  when  other  food  is  given  at  the  same  time.  When 
the  time  for  such  atlditions  arrives,  either  the  first  or  the  second  meal 
may  constitute  the  breakfast,  according  to  convenience  in  its  preparation, 
the  third  the  dinner,  and  the  fourth  the  supper.  The  remaining  morning 
feeding  and  that  in  the  late  evening  should  then  consist  only  of  the 
milk  and  cereal  contents  of  the  bottle.  The  juice  of  half  an  orange 
should  be  given  each  morning  at  least  one  hour  before  a  feeding,  or, 
if  not  obtainable,  the  juice  of  a  ripe  peach  may  be  substituted.  Many 
healthy  children  t]n'iv(>  on  this  diet  of  plain  milk,  cereal,  and  fruit-juice 
and  rcHjuire  no  other  addition.  Children  of  poorer  nutrition  who  cannot 
digest  plain  milk,  or  those  long  fed  on  the  bottle  and  showing  even 
slight  rachitic  symptoms,  require  other  forms  of  proteid  which  they 
may  be  able  to  assimilate  more  readily  than  those  of  milk.  These  may 
rec(>ive  once  daily  the  white  o:  one  egg  mixed  with  the  contents  of  the 
bottle  and  freed  from  stringy  masses  by  straining,  or  one  to  four  table- 
spoonfuls  of  beef-juice  given  at  the  mid  iay  meal,  or  two  to  four  ounces  of 
chicken-broth  or  mutton-broth.  Dry  bread-crusts  or  zwieback  may  suit 
the  requirements  of  some  children  while  not  necessary  for  others.  The 
above  range  of  articles  may  only  be  exceeded  upon  definite  indications. 


DIET  FROM  FIFTEENTH  TO  EIGHTEENTH  MONTH. 

The  sanu>  number  of  f(>edings  should  usually  be  given  during  these 
months.  Children  who  have  recpiired  up  to  the  fifteenth  month  only 
milk  and  cereals  may  now  receive  the  additions  to  their  diet  provided 
for  in  the  previous  section.  For  the  others  a  soft-boiled  egg  may  be 
given  twice  or  three  times  a  week  at  a  morning  or  midday  meal,  and 
the  dry  bread  and  zwieback  may  be  increased  if  already  included  in 
the  dietary.  Thoroughly  cooked  rice  may  be  allov.ed  in  the  broth. 
A  further  range  of  fruit  juices  may  be  obtained  by  using  those  from 
ripe  berries. 


SUBSTITUTE  INFANT  FEEDING  173 

DIET  FROM  EIGHTEENTH  MONTH  TO  TWO  YEARS. 

The  child  should  now  be  able  to  eat  from  a  spoon  and  have  been 
taught  to  drink  some  of  its  milk  from  a  cup.  Plain  milk  may  replace 
that  previously  given  with  cereal  jelly,  and  a  moderate  amount  of  strained 
cereal  over  which  milk  or  equal  parts  of  milk  and  cream  have  been 
poured  given  at  breakfast  and  supper,  farina  alternating  with  bread 
and  milk  at  the  latter  meal.  Scraped-meat  pulp  may  be  replaced  by 
finely  minced  meat  when  dentition  is  sufficiently  advanced.  Apple- 
sauce or  the  pulp  of  baked  apple  or  stewed  prunes  once  a  day.  Toward 
the  end  of  the  year  spinach,  stewed  celery,  green  peas,  and  string  beans, 
each  of  which  have  been  run  through  a  colander,  may  be  tried  one  at  a 
time,  as  well  as  a  part  of  a  mealy  baked  potato  seasoned  with  salt  or 
butter  or  moistened  with  broth  or  meat-juices.  In  my  opinion  the  late 
evening  bottle  (9  to  10  p.m.)  may  well  be  retained  throughout  and 
possibly  beyond  this  period,  as  the  additional  nourishment  makes  it 
possible  to  give  simpler  meals  during  the  day,  since  the  child  will  often 
take  no  more  than  six  to  eight  ounces  of  milk  at  meals  where  it  receives 
other  food,  but  when  the  child  has  attained  to  a  fair  range  of  diet  this 
may  be  discontinued  and  the  number  of  meals  reduced  to  four.  The 
season  of  the  year,  the  child's  digestion,  and  the  amount  of  out-door 
exercise  should  influence  us  in  increasing  or  decreasing  the  dietary. 
In  the  hot  summer  months,  especially,  care  is  necessary,  and  the  less  the 
digestion  is  taxed  the  less  the  liability  to  serious  disturbance. 

During  the  eruption  of  teeth,  if  the  nervous  system  is  perturbed,  the 
diet  should  be  simplified,  since  more  time  and  ground  may  be  lost  by 
a  digestive  upset  than  would  be  gained  by  pushing  the  food.  Foul- 
smelling  stools  or  those  containing  undigested  food  give  us  warning,  and 
call  for  a  return  to  a  simplified  diet  or  even  to  milk  alone  for  a  time 
without  waiting  for  more  serious  symptoms  to  develop. 

Desserts  had  better  be  withheld  until  the  third  year.  If  given  at  all 
they  should  consist  of  junket,  unsweetened  custard,  cornstarch,  and 
plain  rice-pudding  without  raisins.  The  diet  already  outlined  gives 
ample  variety  for  a  child's  needs.  Children  whose  digestions  are  kept 
in  good  condition  do  not  need  constant  changes  to  stimulate  appetite 
and  are  satisfied  with  a  simple  regime.  Children  should  not  be  allowed 
to  know  the  taste  of  candy  and  sweets.  I^hey  will  elaborate  from  their 
starches  all  the  sugar  they  require,  and  it  is  the  beginning  of  endless 
trouble  when  they  realize  the  existence  of  articles  which  taste  better 
than  their  every-day  food.  Mothers  are  constantly  inquiring  whether 
a  little  of  this  or  that  would  hurt  the  baby.  The  difference  between  the 
plain  fare  which  can  be  taken  safely  and  those  things  which  might  not 
cause  disturbance  is  a  wide  one — between  lies  debatable  ground  upon 
which  it  is  folly  to  tread.  The  giving  of  tastes  of  this  or  that  food  has 
its  true  basis  quite  as  much  in  the  selfish  gratification  of  the  giver  as 
in  the  pleasure  of  the  child.  For  this  reason  young  children  should, 
if  possible,  be  given  their  meals  by  themselves  and  not  at  table  with 


174  I. \ FA. XT   FEEDISr, 

adults  or  older  c-liildren,  for  in  the  latter  ease  they  will  inevitably  secure 
unsuitable  articles  either  by  stealth  or  through  importunity.  Children 
may  often  be  induced  to  eat  more  of  certain  ])lain  but  nourishing  dishes 
by  giving  these  first  while  they  are  hungrv  and  reserving  those  for  which 
they  show  the  greatest  fondness  to  be  placed  before  them  at  the  end  of 
the  meal. 

DIET  DURING  THIRD  AND  FOURTH  YEARS. 

The  articles  already  mentioned  give  a  sufficient  range  until  a  child  is 
two  and  one-half  years  of  age,  and  in  practice  it  is  often  wisdom  to 
wait  until  the  third  year  before  giving  meat,  many  of  the  above  vegetables, 
and  preferably  any  form  of  dessert.  By  the  thirtieth  month  the  range 
of  well-cooked  cereals  may  be  increased.  Absolutely  fresh  fish  of  firm 
white  meat,  mashed  cauliflower,  sfpiash,  and  strained  tomatoes  may 
now  be  tried.  Among  the  fruits  the  pulp  of  fresh,  ripe  pears  and  peaches 
may  l)e  allowed  in  small  amounts.  Raw  apples  and  bananas  and  the 
small  seed  berries  should  be  barred  a,s  sources  of  danger,  but  the  juice 
of  the  latter  may  be  allowed  as  previously.  Plain  vanilla  ice-cream  is 
permissible,  but  n(^t  exceeding  twice  a  week.  Definite  hours  for  meals 
should  be  established,  and  the  pernicious  habit  of  eating  between  meals 
discountenanced. 


DIET  FROM  FIFTH    TO    EIGHTH   YEAR. 

This  is  still  an  important  period  over  which  a  sufficient  supervision 
is  rarely  exercised.  During  this  time  the  chikl  lays  an  almost  equally 
important  foundation  for  future  years,  although  the  immediate  danger 
from  digestive  disturbances  is  vastlv  decreased.  The  habit  of  eating 
simple,  nutritious  food  in  good  variety  should  now  be  formed.  The 
natural  preference  for  sweet  articles  to  the  exclusion  of  plain  food  should 
be  combated  h\  withholding  the  former.  A  child  should  never  be 
coaxed  to  eat  by  the  introduction  of  jams,  jellies,  preserves,  syrup,  or 
candy.  If  the  child  fed  on  plain  food  shows  a  continued  lack  of  a])petite 
it  requires  medical  attention.  It  is  a  common  experience  to  find  thin, 
poorly  developed,  and  often  anemic  children  with  coated  tongues  and 
without  appetite,  in  whom  both  appetite  and  nutrition  may  be  restored 
by  absolutelv  forl)idding  all  candv,  sugar,  and  sweet  foods,  and  giving 
some  simple  tonic,  such  as  the  bitter  wine  of  iron,  after  meals.  No  food 
should  be  given  except  at  meal-tiine.  Dry,  canned,  smoked,  salted,  and 
preserved  meats  and  foods  should  be  avoided.  IVa,  coffee,  i)eer,  and 
even  cocoa  are  unnecessary  and  have  no  place  in  the  dietary  of  children, 
a,s  also  highly  seasoned  and  made  dishes,  cake  and  sweet  desserts.  It 
is  a  good  rule  that  they  should  have  only  such  plain  food  as  would  be 
allowed  a  convalescent  adult.  They  will  thus  escape  with  fewer  acute 
illnesses,  and  approach  puberty  with  sound  digestions,  better  physiques, 
and  normal  appetites. 


SEOTIOK  IV. 
DISEASES  OF  THE  ALIMENTARY  TRACT. 


Br  DAVID  BOVAIRD,  Jr.,  M.D, 


CHAPTER    IX. 

DISEASES  OF  THE  MOUTH  AND  PHARYNX. 

DISEASES  OF  THE  MOUTH. 

CATARRHAL  STOMATITIS. 

This  form  of  inflammation  of  the  buccal  mucous  membrane  and 
tongue  is  most  common  to  the  first  year  of  hfe,  but  is  not  uncommon 
in  the  later  periods.  Often  it  is  an  independent  affection,  produced  by 
uncleanliness  or  lack  of  care,  or  by  some  form  of  irritation,  chemical, 
mechanical,  or  thermal.  It  regularly  occurs  with  any  febrile  afi^ection 
that  is  prolonged  for  many  days,  and  especially  with  such  as  are  due 
to  inflammatory  disturbances  in  any  part  of  the  alimentary  tract, 
particularly  the  diarrheal  diseases.  It  is  observed  in  children  who 
are  fed  improper  food.  It  may  occur  in  the  eruptive  fevers,  but  it 
is  certainly  stretching  the  conception  of  a  catarrhal  affection  to  make  it 
include  all  the  varied  changes  in  the  buccal  mucous  membrane  that 
occur  in  measles,  scarlet  fever,  and  like  affections.  Local  lesions, 
especially  decayed  teeth,  may  produce  a  catarrhal  stomatitis,  and  I 
believe  that  I  have  seen  it  produced  by  the  continued  use  of  the 
popular  pacifier. 

In  some  cases  dentition  may  excite  this  process.  Infection  may 
possibly  be  concerned  in  the  etiology,  but  the  mouth  is  such  a  store- 
house of  bacteria  that  it  is  difficult  to  identify  any  as  the  excitants  of 
disease.  More  or  less  general  catarrhal  stomatitis  is  regularly  associated 
with  the  presence  of  the  severer  types  of  inflammation  of  the  mouth, 
ulcerative,  aphthous,  etc. 

Lesions. — The  mucous  membrane  of  the  mouth  is  congested,  the  finer 
capillaries  are  dilated,  and  in  the  severer  cases  there  may  be  minute 
hemorrhages  into  the  tissues,  or  bleeding  may  be  produced  by  slight 
traumatism.  The  mucous  membrane  may  be  swollen  and  the  tongue 
may  appear  correspondingly  large  and  thick.     The  dorsal  surface  of 

(175) 


17G  DISEASES  OF   THE  ALIMENTARY   TRACT 

the  tongue  is  regularly  eoated  with  a  white,  yellowish,  or  brown  fur; 
the  edges  are  red. 

The  normal  secretion  of  the  miuous  nienihrane  is  arrested  in  the 
earlier  and  increased  in  the  later  stages  of  the  all'cction.  The  duration 
of  the  disease  is  dcterniined  mainly  hy  the  nature  of  the  exciting  cause. 
As  an  independent  affection  catarrhal  stomatitis  will  run  its  course 
within  a  week.  When  associated  with  the  fevers  it  may  persist  until 
the  underlying  condition  mends. 

Symptomatology. — The  symptoms  comprise  those  of  any  catarrhal 
inflannnation  of  a  nuicous  membrane— redness,  swelling,  pain — and 
either  a  diminished  or  increased  secretion  of  mucus.  There  is  usually 
an  increased  local  temperature.  The  soreness  of  the  mouth  may  be 
slight  or  may  be  severe  enough  to  seriously  interfere  with  the  feeding  of 
the  child.  The  child  may  be  very  fretful  and  peevish  and  refuse  nourish- 
ment because  of  the  pain.  In  protracted  fevers  the  condition  of  the 
mouth  may  be  for  this  reason  an  important  factor  in  determining  the 
outcome  of  the  disease.  Constitutional  symptoms  are  not  commonly 
seen,  but  a  slight  rise  of  temperature  may  be  noted,  and  vomiting  may 
occur.  On  inspection  we  can  see  the  reddenetl,  swollen  nuicous  mem- 
brane, possibly  showing  minute  hemorrhages,  either  dry  and  glazed 
or  bathed  in  an  increased  secretion  of  mucus.  In  the  later  stages  the 
membrane,  particularly  that  of  the  tongue,  may  be  cracked  or  deej)ly 
fissured,  and  covered  with  a  deposit  of  thick  mucus  and  exfoliated 
epithelium.  There  is  not  any  involvement  of  the  lymph  nodes,  as  a 
rule,  but  in  the  severer  cases  they  may  become  slightly  swollen  and 
tender. 

Diagnosis. — The  local  appearances  are  characteristic.  The  most 
important  point  in  the  examination  of  the  mouth  is  to  determine  the 
presence  or  absence  of  any  causative  factor,  such  as  decaying  teeth,  or 
of  other  and  more  serious  lesions,  such  as  aphthje,  ulcerations,  etc. 
Thorough  examination  is  very  important,  and  to  secure  this  one  must 
know  how  to  handle  children.  For  a  satisfactory  examination  of  the 
mouth  in  an  infant  or  young  child  the  nurse  or  mother  should  stand 
with  the  child  and  turn  it  to  face  the  light  and  the  physician.  The 
mother  should  with  one  arm  clasp  the  legs  and  with  the  other  the 
hands,  so  that  the  child's  head  falls  on  her  right  shoulder.  The 
physician  can  then  control  the  head  with  his  left  hand,  while  with  the 
right  he  uses  a  spatula  or  spoon  to  open  the  mouth,  depress  the  tongue, 
retract  the  cheeks,  etc.  For  the  purpose  of  a  spatula  the  little  flat 
sticks  adopted  by  the  Department  of  Health  of  N(>w  York  are  most 
satisfactory.  'Fhey  will  not  slip  as  the  polished  spatula  does,  and  are 
so  inexjxMisive  that  they  may  be  thrown  away  or  burned  after  using,  as 
the  nature  of  the  case  recjuires. 

Treatment. — For  the  primary  cases  the  removal  of  the  cause,  if  dis- 
coverable, may  be  all  that  is  required.  Usually  some  local  treatment 
is  necessary.  In  the  fel)rile  affections,  and  particularly  the  eruptive 
affections  and  diarrheal  diseases,  the  care  of  the  mouth  is  of  very  great 
importance,  because  of  the  interference  with  feeding  which  results  from 


DISEASES  OF   THE  MOUTH   AND   PHARYNX  177 

the  stomatitis,  and  the  possibihty  that  a  comphcating  pneumonia  may 
be  caused  by  neglect  in  this  particular.  Thorough  cleanliness  and  the 
use  of  some  mild  antiseptic  wash  to  prevent  decomposition  of  the  normal 
secretions  are  essential,  both  in  prophylaxis  and  in  treatment  of  catarrhal 
stomatitis.  After  each  feeding  the  mouth  should  be  cleansed  with  a 
2  per  cent,  solution  of  boric  acid  or  some  equivalent.  There  are  a 
number  of  proprietary  mixtures  which  are  very  serviceable  in  this 
regard,  because  they  meet  the  indications  and  are  at  the  same  time 
agreeable  to  the  patient.  Among  these  may  be  mentioned  glycothy- 
moline  and  borolyptol,  each  used  in  a  dilution  of  1  part  to  4  of  water. 
The  nurse  should  swab  the  mouth  with  one  of  these  solutions,  using 
for  the  purpose  absorbent  cotton  wound  upon  the  finger  or  a  small 
stick.  Gentleness  should  be  required,  as  injury  is  readily  done  by 
rough  usage.  In  the  severe  or  protracted  cases  it  may  be  necessary  to 
use  some  astringent  application,  such  as  a  weak  (2  per  cent.)  solution 
of  nitrate  of  silver,  which  may  be  painted  over  the  mucous  membrane 
with  a  camel's-hair  brush  once  a  day  for  several  days  in  succession. 
Alum  in  a  2  per  cent,  solution  may  be  used  in  the  same  way,  or  powdered 
alum  may  be  mixed  with  an  equal  quantity  of  bismuth  and  dusted  over 
the  surface,  where  the  process  is  protracted  or  superficial  ulcerations 
have  formed. 

The  feeding  of  the  patient  is  of  importance.  The  food  will  produce 
less  pain  if  given  cold.  If  the  child  altogether  refuses  to  feed  in  the 
normal  manner  it  may  be  fed  by  gavage  as  often  as  may  be  deemed 
necessary.  It  is  not  usually  advisable  to  attempt  to  keep  up  a  program 
of  feeding  every  two  or  three  hours  in  this  manner.  Three  or  four 
feedings  in  a  day  may,  however,  be  given  with  the  tube. 


APHTHOUS  STOMATITIS. 

Aphthous  Stomatitis  is  also  called  Aphthae,  Herpetic  Stomatitis, 
Herpes,  but  the  first  designation  is  most  descriptive. 

Etiology. — On  this  point  there  is  little  known.  The  affection  is 
relatively  rare  among  infants  in  their  first  year,  but  is  common  during 
the  second  and  later  years  of  childhood.  Many  authors  regard  it  as  of 
nervous  origin.  French  writers  especially  consider  aphthous  stomatitis 
as  an  infectious  and  contagious  disease  identical  with  the  foot-and- 
mouth  disease  of  cattle  and  transmitted  from  cattle  to  children  by 
means  of  the  milk,  but  the  evidence  of  this  relationship  is  not  satisfactory. 
The  French  also  describe  herpes  of  the  mouth  as  a  distinct  and  inde- 
pendent affection.  Aphthous  stomatitis,  as  we  see  it,  is  regularly  asso- 
ciated with  digestive  disorders,  but  whether  as  cause  or  effect  we  are 
not  prepared  to  say.  There  is  no  evidence  of  its  communication  from 
one  child  to  another. 

Aphthous  stomatitis  is  often  associated  with  dentition.  Baginsky 
thinks  that  it  is  especially  frequent  in  children  living  in  damp,  newly 
built  houses  or  in  badly  ventilated  dwellings.  He  also  says  that  it  may 
12 


178  DISEASES  OF   THE   A  LI  M  EXT  ART    TRACT 

occur  in  several  nieml)er.s  of  a  family,  but  that  evidence  of  its  transmission 
from  one  to  another  is  lacking.  Forchlieimer  and  others  consider  the 
affection  as  analogous  to  herpes.  The  variety  of  views  regarding  its 
nature  is  suHicicnt  evidence  of  the  incompleteness  of  our  knowledge. 

Lesion. — In  its  earliest  stages  this  is  a  vesicle,  formed  hy  an  exudation 
between  the  superficial  epithelium  and  the  underlying  mucosa.  The 
epithelium  is  (juickly  destroyed  and  there  is  left  a  superficial  ulceration, 
small,  round,  not  indurated,  ringed  about  with  a  narrow  zone  of  bright- 
red  congestion.  The  Hoor  of  tiie  ulcer  is  at  first  yellowish,  its  diameter 
commonly  3  to  4  millimetres;  in  its  later  stages  the  color  nuiy  become 
a  dirtv  gray.  The  ulcers  are  usually  scattered,  are  most  numerous  upon 
the  tongue  and  inner  surface  of  the  cheeks,  but  may  occur  upon  any 
part  of  the  mucous  membrane  of  the  mouth  or  ])harynx,  even  upon  the 
tonsils.  Occasionally  they  become  so  numerous  as  to  fuse  into  one 
another  and  form  ulcerations  of  considerable  extent,  but  still  superficial. 
In  the  cases  commonly  seen  there  are  not  more  than  six  or  eight  ulcers 
in  the  mouth.  Various  V)acteria  have  been  found  in  the  lesions,  but  no 
specific  relation  has  been  demonstrated  between  them  and  the  lesions 
of  the  disease. 

Symptomatology. — With  or  without  fever  the  characteristic  lesions 
appear  in  the  mouth.  Usually  for  several  days  there  is  an  eruption 
of  new  spots.  The  gums  are  swollen  and  the  whole  mucous  membrane 
is  deeply  injected.  The  tongue  is  heavily  coatetl  white.  There  is  a 
profuse  salivation.  The  ulcers  are  extremely  painful  and  the  children 
are  consecjuently  restless,  fretful,  and  refuse  to  eat.  The  affection  tends 
naturallv  to  recovery  in  from  one  to  two  weeks. 

Diagnosis.— This  must  rest  upon  the  characters  of  the  local  lesion. 
The  round  form,  discrete  distribution,  superficial  character  of  the 
ulcers,  together  with  the  bright-red  ring  of  congestion  about  them,  are 
distinctive.  The  fetid  odor  of  ulcerative  stomatitis  is  never  present, 
although  the  breath  may  be  heavy. 

Treatment. — This  is  essentially  the  same  as  that  of  the  catarrhal 
stomatitis,  except  that  the  pain  can  be  considerably  relieved  and  progress 
hastened  by  touching  the  ulcers  with  a  lump  of  alum  or  by  tlusting  pow- 
dered burnt  alum  upon  them.  In  protracted  cases  nitrate  of  silver  may 
be  used.  Peroxide  of  hydrogen  diluted  with  3  or  4  parts  of  water  forms 
an  excellent  mouth  wash  or  application  for  cases  of  this  kind.  Instead 
of  the  alum,  potassium  permanganate  1  :  15  may  be  applied  with  a 
brush  to  the  lesions  daily  for  several  successive  days.  If  these  appli- 
cations do  not  sufficiently  relieve  the  pain,  cocaine  in  2  percent,  solution 
may  be  similarly  applied  to  the  lesions,  but  this  is  usually  unneces- 
sary. 

The  internal  administration  of  potassium  chlorate  or  other  remedies 
may  be  dispensed  with.  As  already  noted,  the  disease  is  usually  self- 
limited.     The  object  of  treatment  is  mainly  to  relieve  the  discomfort. 

At  the  onset  a  dose  of  castor  oil  or  calomel  is  advisable  to  move  the 
bowels  freely.  Milk  of  magnesia  is  a  useful  laxative.  The  diet  should 
be  milk  modified  to  suit  the  digestive  powers  of  the  child. 


DISEASES  OF   THE  MOUTH  AND   PHARYNX  I79 


ULCERATIVE  STOMATITIS. 

This  affection  is  never  seen  in  infancy  before  the  eruption  of  the  teeth. 
It  is  common  after  the  second  year  of  childhood,  and  it  may  occur  at 
any  age.  In  the  great  majority  of  cases  it  is  to  be  attributed  to  bad 
hygienic  conditions.  It  is  rarely  seen  in  private  practice,  but  is  extremely 
common  in  children  confined  in  hospitals  and  asylums.  It  is  a  frequent 
sequel  of  infectious  diseases,  especially  measles,  typhoid,  pneumonia, 
etc.  It  is  this  form  of  stomatitis  which  is  a  regular  accompaniment  of 
scurvy,  and  doubtless  defects  in  diet  are  responsible  for  the  frequency 
of  its  occurrence  in  hospital  and  asylum  children.  Ulcerative  stomatitis 
may  be  produced  by  the  excessive  use  of  mercury,  iodine,  lead,  or 
phosphorus,  but  except  from  mercury  we  rarely  see  it  caused  in  this 
way.  It  is  held  by  some  to  be  a  contagious  affection.  Forchheimer  says 
that  under  proper  conditions  it  can  be  transmitted,  but,  as  a  matter  of 
practical  experience,  contagion  appears  to  play  no  part  in  its  distribution. 
Lack  of  care  of  the  mouth  and  teeth,  and  especially  neglect  of  decaying 
teeth,  seem  to  be  important  factors  in  the  production  of  this  affection. 
No  specific  organism  has  yet  been  found. 

Pathology. — There  is  an  intense  general  catarrhal  stomatitis,  the  gums 
especially  being  swollen,  so  that  they  may  almost  cover  the  teeth.  They 
are  deep  purple  in  color  and  bleed  very  easily.  The  characteristic 
lesion  is  that  of  necrosis  and  death  of  that  portion  of  the  gums  which 
extends  upward  on  the  teeth.  This  part  of  the  gums  at  first  shows  a 
yellowish  line  of  necrotic  tissue;  later,  the  dead  tissue  becomes  dark 
gray  or  black  and  sloughs  off,  leaving  a  raw,  bleeding  surface.  There  is 
a  mucopurulent  exudation  between  the  gums  and  the  teeth,  which  are 
loosened  in  their  sockets  and  may  even  be  entirely  detached.  Similar 
death  of  tissue  and  ulceration  may  appear  on  other  parts  of  the  mucous 
membrane  of  the  mouth,  especially  on  the  inner  surface  of  the  lips  and 
cheeks  opposite  the  teeth,  but  the  ulceration  never  extends  beyond  the 
limits  of  the  mouth.  The  submaxillary  and  anterior  cervical  lymph  nodes 
are  regularly  swollen  and  tender. 

Cornil  and  Ranvier  describe  the  pathological  process  as  a  diffuse 
infiltration  of  the  lymph  spaces  of  the  tissue  with  pus  and  fibrin,  by 
which  the  capillaries  of  the  part  are  compressed,  and  the  circulation 
checked,  so  that  the  death  of  the  part  follows  exactly  as  in  a  phlegmon 
of  the  subcutaneous  tissues. 

The  ulcerations  produced  on  the  mucous  membrane  are  irregularly 
round  in  outline,  moderately  deep,  the  edges  ragged,  the  base  a  dull 
gray  or  grayish  black,  covered  with  thick  mucopus  of  an  extremely 
fetid,  offensive  odor.  The  ulcers  are  of  any  size,  often  becoming  extensive. 

In  severe  cases  the  periosteum  of  the  jaw  may  be  involved  and  there 
may  be  extensive  necrosis  of  the  bone,  sequestra  of  considerable  size 
being  removed. 

Symptomatology. — Attention  is  usually  attracted  to  the  condition  of 
the  mouth  either  by  complaint  of  pain  in  eating  or  by  the  profuse 


ISO  DISEASES  OF   THE   MAMENTARY    TRACT 

salivation  and  \\w  very  fetid  odor  of  the  breath.  On  inspection  of  the 
mouth  we  usually  find  the  mucous  mciui)rane  everywhere,  hut  especially 
the  gums,  swollen,  deep  purple,  sjwngy-feelinii;,  and  l)leedin<r  at  the 
slightest  touch,  while  about  the  roots  of  some  of  the  teeth,  most  often 
of  the  lower  incisors,  but  sometimes  the  molars,  there  is  the  charac- 
teristic yellowish  or  gray  line  of  necrotic  tissue.  Ulceration  of  the 
mucous  membrane  may  l>e  found,  ])articularly  in  the  fold  passing  from 
the  jaw  to  the  inner  surface  of  the  lips,  or  op{)osite  the  molar  teeth. 
These  ulcers  have  the  characteristics  already  described.  Profuse  sali- 
vation is  noted  and  from  this  there  may  be  extensive  excoriation  and 
eczema  of  the  lips  or  skin  wet  by  the  saliva.  The  swollen  submaxillary 
and  cervical  lymph  nodes  can  be  felt. 

The  afi'ection  is  extremely  painful,  the  children  are  restless  and  peevish 
and  greatly  depressed,  as  a  rule,  because  of  their  inability  to  take  nour- 
ishment. The  temperature  may  be  slightly  elevated  in  the  begiiming, 
but  is  usually  normal.  The  offensive  fetid  odor  exhaled  by  the  patient's 
breath  and  the  saliva  is  perceptible  even  at  a  distance.  The  patients 
will  hardly  touch  food  or  drink,  because  of  the  severe  pain  excited. 

In  favorable  cases  the  necrotic  tissue  soon  sloughs  off,  leaving  raw, 
bleeding  surfaces,  the  swelling  of  tha  mucous  membrane  subsides,  the 
ulcers  gradually  heal,  the  salivation  subsides,  and  the  mouth  returns  to 
normal.  This  is  the  ordinary  course,  but  under  unfavorable  conditions 
the  ulceration  of  gums  and  mucous  memlirane  progresses,  the  teeth  are 
loosened  and  fall  out,  and  the  alveolar  process  of  the  inferior  maxilla  may 
be  totally  destroyed.  The  upper  jaw,  if  affected,  is  much  less  seriously 
involved.  These  graver  ravages  are  not  common.  The  affection  usually 
runs  a  favorable  course,  but  at  times  will  persist  for  weeks  or  months 
and  may  seriously  drain  the  child's  vitality  and  impair  nutrition.  More 
or  less  loss  in  these  respects  is  regularly  seen. 

Diagnosis. — Simple  inspection  suffices  for  this  purpose.  The  swollen, 
deep-purj)le  gums;  the  necrotic  line  at  the  roots  of  the  teeth ;the  distribu- 
tion of  the  ulcers  and  their  character;  the  ])rofuse  salivation,  and  the 
fetid  odor  of  the  breath  are  characteristic.  The  ulcers  may  suggest 
diphtheritic  lesions,  but  the  absence  of  a  diphtheritic  process  in  the  throat 
and  the  results  of  cultures  will  promptly  settle  the  question  if  the  local 
appearances  are  confusing. 

At  times  the  question  may  arise  whether  we  have  to  deal  with  ulcer- 
ative stomatitis  or  noma.  In  noma  the  tissues  have  the  deep  l)lue- 
black  look  characteristic  of  gangrene,  the  odor  is  characteristic,  and  the 
constitutional  sym])toms  of  high  fever,  marked  toxemia,  and  prostration 
are  enough  to  settle  the  (juestion. 

Treatment. — In  most  cases  impaired  nutrition  from  improper  or 
inadequate  food  or  bad  hygienic  surroundings  is  an  important  factor 
and  requires  attention.  An  antiscorbutic  diet,  with  fresh  milk,  fresh 
fruits  and  vegetables,  will  be  of  hel]).  In  the  early  stages  only  fluids 
or  very  soft  foods  can  be  taken. 

Locally,  we  must  remove  decayed  or  broken  teeth  or  any  other  cause 
of  irritation.     Teeth  that  are  merely  loose  may  be  spared  in  the  hope 


DISEASES  OF   THE  MOUTH   AND   PHARYNX  Igl 

that  they  may  be  retained,  but  where  necrosis  of  the  alveolar  process 
occurs  it  will  be  necessary  to  remove  the  affected  teeth  and  scrape  away 
the  softened  bone  or  wait  for  the  separation  of  a  sequestrum. 

The  use  of  a  detergent  and  antiseptic  mouth  wash,  as  in  the  catarrhal 
stomatitis,  is  helpful.  If  the  child  is  not  old  enough  to  use  a  mouth  wash 
itself,  the  nurse  or  mother  may  be  directed  to  cleanse  the  mouth  after 
each  feeding  in  the  manner  described  under  catarrhal  stomatitis.  Great 
gentleness  will  be  required  in  any  such  manipulations.  Potassium 
chlorate  is  regarded  as  a  specific  for  this  affection.  It  is  regularly  given 
internally  and  may  be  employed  as  a  mouth  wash.  It  may  be  given 
simply  dissolved  in  water  in  the  proportion  of  0.130-0.195  gm.  to  4  c.c. 
(2  or  3  grains  to  the  drachm) ,  or  in  such  a  prescription  as  the  following : 

5fc — Potassii  chloral  is 6.0  gms.  (5issL 

Acidi  muriatici  dil 4  0  c.c.  (5j). 

Syrupi 15.0   "  (Sss). 

Aquae       .        , q.  s.  ad  120.0    "  (Siv).— M. 

Sig. — 2.0-4.0  c.c.  (Sss-5j)  every  two  or  three  hours. 

1.30-1.95  gm.  (20  to  30  grains)  may  be  given  during  a  day  to  a 
child  of  three  years,  but  such  doses  should  not  be  continued  for  more 
than  a  few  days.  The  potash  has  hemolytic  powers  and  is  capable  of 
producing  an  acute  nephritis,  but  such  results  are  very  rarely  seen.  After 
two  or  three  days  the  mouth  will  begin  to  improve  and  the  doses  should  be 
diminished. 

As  a  mouth  wash  potassium  chlorate  may  be  used  in  the  strength 
of  0.2-0.25  gm.  to  30  c.c.  (3  or  4  grains  to  the  ounce),  but  it  is  rather 
painful  for  such  purpose.  As  the  mouth  improves  the  diet  should  be 
increased  and  nutrition  favored  in  every  possible  way.  Iron  tonics 
may  be  employed,  but  the  best  of  tonics  will  be  fresh  air  and  good  food. 
In  the  protracted  cases  caustics,  such  as  alum  or  nitrate  of  silver  or 
the  potassium  permanganate,  may  be  employed  to  bring  about  healthy 
reaction.  Necrosis  of  bone  may  require  removal  of  teeth  and  scraping 
of  the  alveolar  process,  or  the  removal  of  a  sequestrum  after  separation. 

It  is  to  be  remembered  that  much  destruction  of  bone  may  impair 
or  even  destroy  the  permanent  teeth  and  also  lead  to  considerable 
deformity  from  falling  in  of  the  soft  parts. 


MYCOTIC  STOMATITIS. 

This  is  a  specific  stomatitis  produced  by  the  growth  and  development 
of  a  cryptogam,  and  it  is  commonly  named  thrush.  The  affection  is 
regularly  seen  in  infants  in  the  first  few  months  of  life,  although  it  does 
occur  in  rare  instances  later.  It  is  of  frequent  occurrence  in  hospitals 
and  asylums  unless  great  care  is  taken  of  the  infants'  mouths.  It  is 
not  uncommon  in  dispensary  practice,  among  the  children  of  the  poor 
and  ignorant,  but  is  practically  unknown  where  proper  care  of  the 
newborn  is  taken.  Artificially  fed  infants  suffering  from  intestinal 
disorders  or  any  wasting  disease  seem  to  be  much  more  prone  to 
suffer  from  this  affection  than  breast-fed  and  the  healthy. 


182  DISEASES  OF   THE   AI.IMESTARY    TRACT 

The  fungus  which  j^nxhices  the  disease  is  frequently  found  in  the 
air,  and  infection  may  occur  from  this  source;  but  the  infection  may 
also  be  carried  by  unclean  nipples,  bottles,  cloths,  or  instruments  that 
are  used  in  the  mouth  of  the  infant. 

The  fungus  presents  itself  in  filaments  3  to  4  mm.  wide  and  50  to 
GO  mm.  in  length,  joined  in  long  threads.  At  the  junctions  of  the 
filaments  rounded  cells  branch  off  and  in  these  spores  are  found.  The 
spores  reproduce  the  filaments  or  mycclia.  If  one  of  the  small  whitish 
patches  characteristic  of  the  disease  be  scraped  off  and  put  under  the 
microscope,  either  unstained  or  colored  by  a  methylene-blue  solution, 
it  will  be  found  to  consist  of  epithelial  cells  from  the  tongue,  various 
yeast  cells,  and  the  mycelia  antl  spores  of  the  specific  fungus.  The  exac-t 
classification  of  the  fungus  has  given  rise  to  much  discussion  and  is  still 
unsettled.  By  some  it  has  been  considered  as  identical  with  the  mould 
fungus,  the  oidiura  lactis,  found  in  sour  milk;  by  others  it  is  classed 
w'ith  the  yeast  fungus  or  wine  ferment,  saccharomyces  mycoderma;  still 
others  class  it  as  a  yeast  fungus  not  identical  with  the  last  named  and 
call  it  saccharomyces  albicans.  From  the  practical  standpoint  the 
question  is  not  of  vital  importance. 

Lesions. — The  characteristic  lesion  is  a  minute  white  spot,  the  size 
of  a  pin's  head,  slightly  raised,  occurring  upon  the  tongue  or  any  part 
of  the  raucous  membrane  of  the  mouth.  The  lesions  may  occur  in  the 
larynx,  esophagus,  stomach,  cecum,  and  even,  it  is  said,  in  the  lungs. 
They  are  usually  discrete,  but  may  fuse  and  form  considerable  areas, 
until  the  whole  mouth  is  lined  by  the  whitish  coating.  The  patches 
are  found  to  be  closely  adherent,  so  that  they  are  not  easily  removed. 
If  scraped  off,  they  leave  a  red,  glistening  surface  beneath. 

In  fatal  cases  in  infants  we  find  the  lesions  of  gastric  or  intestinal 
catarrh  or  marasmus.  In  older  children  mycotic  stomatitis  is  usually 
associated  with  tuberculosis,  typhoid,  or  persistent  pneumonia. 

The  severer  types  of  the  disease  are  evidently,  from  the  literature, 
much  more  common  in  Europe  than  in  this  country.  In  several  thousand 
autopsies  at  the  New  York  Foundling  Hospital  but  one  instance  of  the 
finding  of  the  fungus  beyond  the  mouth  has  been  recorded.  In  that 
case  the  fungus  was  found  in  the  stomach  (Northrup). 

Symptomatology. — ^Preceding  the  development  of  the  characteristic 
lesions  of  thrush  the  mucous  membrane  of  the  mouth  is  somewhat 
swollen,  reddened,  and  dry,  as  in  a  catarrhal  stomatitis  the  infant 
will  show  the  usual  distress  in  feeding  and  will  be  restless  and  fretful. 
After  a  day  or  two  the  characteristic  minute  white  patches,  slightly 
raised  above  the  surface,  dry  and  adherent,  appear,  first  upon  the 
dorsum  of  the  tongue,  later  on  the  mucous  membrane  of  the  lips  and 
cheeks,  the  gums,  and  the  palate.  As  the  patches  become  more  numerous 
they  also  increase  in  size  and  may  fuse  into  one  another  until  the  whole 
mouth  is  coated  \\\i\\  a  whitish  pellicle.  In  the  course  of  a  week  the 
patches  assiune  a  grayish  or  yellowish  tint,  become  loosened  from  the 
mucous  membrane,  and  are  gradually  exfoliated,  the  underlying  mem- 
brane being  left  red,  dry,  and  with  prominent  })apillce.     The  affection 


PLATE   IV, 


Fiy.  1 


Fig.  Ill 


Fi.)    ]I 


Fig   V 


Fig.     I.  Thrush. 
"      II.  Ulcerative  Stomatitis. 
"    III.   Aphthous  Stomatitis. 
"    IV.  Aphthous  Stomatitis    (late  stage.). 
"      V.  Geographical  Tongue  (Eczema  of  the  Tongue. 


DISEASES  OF    THE   MOUTH   AXD   PHARYNX  183 

then  terminates  by  a  gradual  return  of  the  membrane  to  a  normal 
appearance  or  there  is  a  new  evolution  of  the  plaques  and  a  continuation 
of  the  disease.  During  the  height  of  the  disease  there  may  be  occasional 
vomiting,  loose  yellow  or  greenish  stools,  and  considerable  pain,  restless- 
ness, and  irritability.  The  temperature  may  be  slightly  raised,  but  is 
generally  normal.  As  commonly  seen  the  patches  are  not  very  numerous, 
they  remain  discrete,  and  the  constitutional  disturbance  is  slight.  The 
reaction  of  the  mouth  is  regularly  acid  during  the  course  of  the 
affection. 

Occurring  as  a  complication  of  preceding  diarrheal  disease,  or  in 
athreptic  children  the  affection  not  infrequently  assumes  a  grave  type. 
The  mouth  becomes  coated  with  the  whitish  deposit,  which  may  extend 
into  the  phar^mx,  esophagus,  and  even  into  the  stomach  and  intes- 
tines; vomiting  may  be  frequent,  diarrhea  severe,  with  frequent  green, 
acid  stools,  which  excoriate  the  buttocks  and  any  other  parts  with  which 
they  come  in  contact;  the  temperature  may  be  high,  the  interference 
with  feeding  marked;  the  patients  may  waste  rapidly  and  the  disease 
terminate  fatally. 

Diagnosis. — The  affection  can  usually  be  recognized  at  a  glance.  The 
inexperienced  may  be  misled  by  the  presence  of  little  flakes  of  milk, 
which  may  present  an  appearance  not  unlike  the  patches  of  thrush. 
The  milk  flakes  are,  however,  easily  brushed  off;  thrush  plaques  are, 
during  the  early  days  of  the  disease,  c|uite  firmly  adherent.  If  doubt 
remains  in  any  case  it  can  at  once  be  settled  by  scraping  off  one  of  the 
little  patches  and  examining  it  under  the  microscope  for  the  specific 
fungus.  The  ulcerative  aft'ections  can  be  readily  distinguished  by  the 
destruction  of  epithelium  and  the  consequent  depressions.  Thrush  is 
a  deposit  elevated  above  the  surrounding  surface.  The  lesions  of 
aphthous  stomatitis  present  a  superficial  ulceration,  are  yellowish  in 
color  and  usually  ringed  with  a  bright  zone  of  congestion.  The  salivation 
seen  in  these  ulcerative  diseases  does  not  belong  to  thrush. 

Diphtheritic  stomatitis  is  usually  limited  to  one  or  more  patches,  and 
is  accompanied  by  diphtheritic  lesions  of  the  throat. 

The  microscopic  examination  is  conclusive  in  any  case. 

Prognosis. — This  is  usually  very  favorable.  As  ordinarily  seen  the 
cases  are  mild  and  reheved  in  a  few  days.  It  is  to  be  remembered, 
however,  that  in  children  already  exhausted  by  preceding  disease 
thrush  may  prove  a  serious  and  even  fatal  complication. 

Treatment.  Prophylaxis. — This  is  of  the  utmost  importance  in  all 
cases,  and  especially  in  hospitals  and  asylums.  Strict  cleanliness  of  the 
infant's  mouth  is  the  first  essential.  The  mouth  should  be  cleansed 
after  every  feeding  with  a  2  per  cent,  boric  acid  solution.  The  cleansing 
is  best  done  by  the  use  of  absorbent  cotton  wound  on  the  nurse's  little 
finger  or  a  stick  and  then  wet  with  the  solution.  If  for  any  reason  this 
method  is  undesirable  a  soft  brush  may  be  used  as  a  swab.  The  next 
important  point  is  the  regular  cleansing  and  sterilization  of  bottles 
and  nipples  used  in  feeding,  and  of  any  instruments  or  articles  that 
it  may  be  necessary  to  put  into  the  infant's  mouth.     After  cleansing, 


184  DISEASES  OF  THE  ALIMEXTARY   TRACT 

bottles  and  nipples  should  be  kept  in  ;i  2  per  tent,  borie  acid  solution 
until  used. 

By  strict  attention  to  these  (letails  tlie  aH'cction  has  l)een  banished 
from  modern  lying-in  institutions,  but  any  relaxation  of  care  is  (piite 
sure  to  be  followed  by  an  outbreak  of  the  disease. 

Curative. — The  same  methods  are  usually  adecpuite  to  remove  the 
disease  after  it  has  appeared.  Instead  of  the  boric  acid,  2  per  cent, 
sodium  bicarbonate  may  be  t^nployed.  The  systematic  use  of  these 
solutions  will  usually  result  in  a  prompt  cure.  In  rebellious  or  severe 
cases  stronger  solutions  may  be  necessary.  A  saturated  solution  of  boric 
acid  may  be  applied  three  or  four  times  a  day.  Bichloride  of  mercury 
1  :  1000  may  be  apj)lied  once  or  twice  a  day. 

Where  it  "seems  desirable  to  prolong  the  effect  of  the  application  this 
may  be  done  by  dissolving  the  antiseptic  in  glycerin,  as  in  the  following: 

Jfc— Boracis, 

Sodii  bicarbonatis Cm      4.0  gms.     (r>j). 

Glycerini 30.0  c.c.       (5j).— M. 

This  solution  can  be  painted  on  with  a  brush.  For  still  more  powerful 
effect  permanganate  of  potassium,  1  :  250,  or  2  per  cent,  silver  nitrate 
solution  may  be  employed  with  a  brush.  Whatever  application  is  made 
care  should  be  taken  to  avoid  any  further  injury  to  the  epithelium. 
In  the  severer  types  of  the  affection,  met  with  secondarily  in  the  diar- 
rheal diseases,  etc.,  special  attention  will  be  required  to  the  feeding, 
which  must  be  adju.sted  to  the  disturbed  digestive  functions  of  the 
infant.  Holt  says  that  in  certain  hospital  ca.ses  he  has  found  that  the 
disease  is  .sometimes  protracted  by  the  irritation  produceil  by  the  nipple 
in  feeding,  and  suggests  in  such  cases  resort  to  feeding  by  gavage  for 
several  days. 

PERLECHE. 

Under  this  title  an  ulcerative  affection  of  the  angle  of  the  mouth  was 
originally  described  by  Lemaistre  and  has  since  been  more  thoroughly 
considered  by  Comity. 

Etiology. — The  affection  is  not  uncommon  among  children  from  two 
to  seven  years  of  age  and  may  be  seen  in  the  younger  classes  of  school 
children.  The  fissure  with  which  it  begins  is  doubtless  produced  by 
traumatism;  in  the  later  development  of  the  ulceration  the  practice  of 
constantly  licking  tlie  lips  and  .secondary  infection  by  the  .streptococcus 
or  staphylococcus  appear  to  be  the  most  important  factors.  The  affection 
may  present  itself  in  several  members  of  a  family  and  is  thought  by  some 
to  be  contagious,  transmission  occurring  from  the  u.se  of  unclean  drink- 
ing ves.sels,  etc.,  or  by  ki.ssing. 

Lesion. — This  is  at  first  a  simple  fl.ssure  of  the  angle  of  the  mouth. 
Later  there  tievelops  a  superficial  ulcer  with  a  dirty-gray  base,  and  some 
thin,  purulent  discharge.  The  ulcer  is  not  unlike  the  mucous  patch  of 
hereditary  .syphilis.     Under  unfavorable  conditions  the  ulceration  may 


DISEASES  OF   THE  MOUTH   AND   PHARYNX  185 

become  extensive  and  there  may  be  destruction  of  the  surrounding  skin. 
Usually  there  is  no  involvement  of  the  lymph  nodes,  but  in  the  severe 
cases  this  may  occur.  The  ulceration  is  usually  quite  painful  and  the 
lip  may  be  sw^ollen.  The  affection  is  not  grave,  yielding  readily  to 
treatment. 

Diagnosis. — The  character  and  location  of  the  ulceration  and  the 
absence  of  any  of  the  other  symptoms  of  syphilis  suffice  to  render 
diagnosis  easy. 

Treatment. — This  consists  in  cleansing;  the  ulcer,  touching;  its  surface 
with  a  caustic,  the  nitrate  of  silver  stick,  tincture  of  iodine,  or  burnt 
alum,  and  later  the  application  of  a  protective  ointment,  such  as  one 
of  bismuth  or  zinc  oxide. 


BEDNAR'S  APHTH-ffi. 

By  this  name  certain  superficial  ulcerations,  produced  by  traumatism 
upon  the  hard  or  soft  palate,  have  come  to  be  known.  The  lesions  are 
undoubtedly  produced  by  rough  treatment  in  swabbing  out  the  mouth 
and  occur  just  at  the  points  where  too  great  pressure  would  readily 
tell.  These  are  well  back  upon  the  hard  palate,  just  at  the  junction 
with  the  soft,  and  over  or  close  to  the  velum  of  the  palate.  They  are 
quite  frequently  seen  in  hospital  practice,  rarely  in  private  work.  In 
some  cases  similar  ulcers  are  produced  by  too  large  or  rough  nipples. 
The  ulcers  are  usually  round  or  elliptical,  yellowish  in  color,  and  very 
superficial.  They  are  regularly  seen  during  the  first  weeks  after  birth. 
They  may  be  important  by  reason  of  resulting  difficulty  in  feeding. 

Treatment  should  be  that  of  a  catarrhal  stomatitis,  cleanliness  being 
especially  important,  and  for  obvious  reasons  special  care  should  be 
taken  to  avoid  further  injury  to  the  delicate  mucous  membrane. 

GONORRHEAL  STOMATITIS. 

A  form  of  gonorrheal  involvement  of  the  mouth,  consisting  of  super- 
ficial ulcerations  upon  the  tongue  or  the  palate,  has  been  described 
by  some  writers.  The  infection  occurs  from  the  mother.  The  gono- 
coccus  may  be  demonstrated  in  the  secretions  of  the  ulcers,  and  this 
demonstration  is  essential  to  the  diagnosis.  Very  little  is  known  of 
the  affection  and  it  appears  to  be  a  rare  occurrence. 

Treatment  would  be  that  of  the  catarrhal  stomatitis. 


SYPHILITIC  STOMATITIS. 

Under  this  heading  may  be  included  fissures,  papules,  mucous  patches, 
ulcers  or  primary  sores.  It  is  quite  unusual  to  find  the  primary  lesion 
of  syphilis  in  the  mouth  in  children,  but  it  may  occur  upon  the  lips, 
tongue,  or  tonsil.     Its  characters  and  course  do  not  differ  from  those 


186  DISEASES  OF   THE  ALIMEXTARY   TRACT 

observed  in  later  life.  Fissures  of  the  mucocutaneous  surface  of  the 
lip  arc  common  and  well-known  manifestations  in  congenital  syphilis. 
The  fissures  are  most  often  seen  at  the  angles  of  the  mouth,  but  are  not 
limited  to  that  site.  They  may  be  deep,  they  bleed  easily,  and  are 
painful.  There  may  be  some  induration  ^bout  them.  They  should 
not  be  confused  with  the  simple  fissures  seen  in  poorly  nourished 
children  during  or  after  the  exanthemata  or  other  severe  illness.  The 
syphilitic  fissures  are  very  chronic  and  difficult  to  heal.  They  regularly 
leave  cicatrices  which  often  produce  deformities  of  the  lip  that  are  quite 
characteristic.     (See  chapter  on  Congenital  Syphilis,  p.  5G2.) 

The  mucous  patches  occur  upon  the  lips  or  any  part  of  the  buccal 
mucous  membrane.  These  are  usually  round,  of  a  grayish-white  color, 
sharply  limited,  and  slightly  raised  above  the  surface.  They  are  not, 
as  a  rule,  painful.  Papules,  the  condylomata  lata,  are  not  frecjuent,  but 
may  occur  about  the  mouth.  They  are  usually  broad,  their  surface 
irregular,  the  centres  soft  and  exude  a  purident  secretion. 

Diagnosis. — While  the  apj)earance  of  these  local  lesions  is  often 
characteristic,  it  is  certainly  unsafe  to  venture  a  diagnosis  in  the  al)sence 
of  other  evidences  of  syphilis,  the  coryza,  adenopathy,  laryngitis,  or 
erujitions. 

Treatment. — The  constitutional  treatment  of  syphilis  is,  of  course, 
essential,  and  is  mentioned  in  detail  in  another  chaj^ter.  Where  the 
local  lesion  permits,  mercurial  ointment  may  be  applied  to  it,  or  it 
may  be  dusted  with  a  powder  of  equal  parts  of  calomel  and  bismuth. 
The  mouth  should  be  kept  thoroughly  clean  by  the  use  of  one  of  the 
detergent  mouth  washes. 


DIPHTHERITIC  STOMATITIS. 

This  is  one  of  the  possible  complications  of  diphtheria  in  general.  In 
my  experience  it  is  never  seen  in  the  absence  of  diphtheritic  affection 
of  the  pharynx  and  tonsils.  In  the  mouth  the  diphtheritic  plaques  may 
occur  on  any  part  of  the  mucous  membrane,  but  especially  on  the 
tongue  or  the  inner  surface  of  the  lips.  In  severe  cases  of  diphtheria  it 
is  not  uncommon  to  see  fissures  at  the  angles  of  the  mouth  covered  with 
membrane.  The  lesions  in  the  mouth  have  all  the  varied  appearance 
of  diphtheria  seen  elsewhere.  As  it  regularly  accompanies  diphtheria  of 
the  throat,  mistake  can  hardly  be  made  in  the  diagnosis.  Xoiwliphther- 
itic  lesions,  the  ulcerative  or  aphthous  stomatitis  covering  large  areas,  are 
sometimes  mistaken  for  diphtheria.  The  local  appearances  ought  to 
decide  the  matter,  but,  if  necessary,  cultures  may  be  made.  In  asso- 
ciation with  diphtheria  of  the  mouth  the  submaxillary  and  adjacent 
lymph  nodes  should  be  swollen  and  tender. 

The  occ-urrence  of  lesions  in  the  mouth  is  of  some  moment  by  reason  of 
the  resulting  pain  and  greater  disinclination  to  the  taking  of  nourishment, 
otherwise  one  should  not  attach  too  grave  importance  to  them.  More 
or  less  catarrhal  stomatitis  is  associated  with  the  diphtheritic  lesions. 


DISEASES  OF   THE  MOUTH  AXD  PHARYNX  187 

Treatment. — Apart  from  the  use  of  antitoxin  this  would  call  for  the 
local  cleansing  applied  to  diphtheria  of  any  part,  by  the  frequent  irriga- 
tion with  normal  salt  solution  or  2  per  cent,  boric  acid.  No  attempt 
should  be  made  to  remove  the  membrane  mechanically,  and  more 
vigorous  treatment  is  usually  more  harmful  than  helpful. 


GANGRENOUS  STOMATITIS. 

This  disease  is  described  under  the  names  of  Noma,  Cancrum  Oris, 
and  Wasserkrebs. 

Etiology. — The  affection  is  not  infrequently  seen  in  large  hospitals 
or  asylums  for  children;  it  is  almost  unknown  in  private  practice.  From 
time  to  time  isolated  cases  are,  however,  reported  in  children  in  homes 
far  removed  from  all  the  usual  influences  or  sources  of  infection.  Un- 
doubtedly bad  hygienic  surroundings  favor  the  outbreak  of  the  affection; 
this  is  implied  in  its  confinement  to  hospitals  and  asylums.  "Whatever 
lowers  the  resisting  power  of  the  child  favors  the  disease,  but  internal 
conditions  are  the  factors  of  greatest  importance.  The  disease  almost 
never  occurs  primarily  but  is  a  sequel  of  some  exhausting  illness,  such  as 
measles,  scarlet  fever,  pneumonia,  typhoid,  whooping-cough,  dysentery, 
tuberculosis,  syphilis,  etc.  Of  all  these  measles  is  par  excellence  the  pre- 
cursor of  cancrum  oris.  The  active  stomatitis  which  regularly  accom- 
panies this  affection  undoubtedly  plays  a  part  in  the  production  of  gan- 
grene. The  disease  is  most  often  seen  in  children  from  two  to  seven  years 
of  age,  but  I  have  seen  it  in  an  infant  of  six  months,  and  Koster,  Hann- 
son,  and  Ziegler  have  reported  cases  ranging  in  age  from  fifteen  to  seventy 
years.  Geographically  its  special  field  lies  in  Denmark,  the  Baltic  coast 
of  Germany,  and  Holland.  The  disease  is  regarded  by  some  as  con- 
tagious, but  the  support  of  this  proposition  is  not  strong.  Blumer  and 
jMacfarlane  have,  however,  reported  an  epidemic  in  the  Albany  Orphan 
Asylum.  In  one  of  the  nurseries  of  the  New  York  Foundling  Hospital  a 
few  years  ago  there  occurred  a  series  of  cases  of  gangrene  of  the  ear,  in 
which  the  transmission  of  the  disease  was  satisfactorily  traced  to  the 
common  use  of  a  syringe  for  irrigation  of  the  ears.  The  outbreak 
stopped  upon  the  introduction  of  proper  methods  of  asepsis. 

Pathology. ^ — ^The  bacteriology  of  gangrenous  stomatitis  is  still  in  dispute. 
Schimmelbusch  in  1SS9  described  a  short  bacillus,  with  rounded  ends, 
occurring  sometimes  as  a  diplobacillus,  sometimes  in  long  filaments, 
which  he  found  in  the  zone  of  invasion  of  the  gangrene  and  which  he 
regarded  as  specific.  Rossi  in  1892  found  streptococci  and  staphylocQCci 
with  many  leptothrix-like  bacilli  in  the  lesions.  Babes  and  Zambilovici 
in  1894  described  another  specific  bacillus.  Blumer  and  JMacfarlane 
found  an  organism  of  the  leptothrix  class.  Others  have  found  the 
diphtheria  and  pseudodiphtheria  bacilli,  but  none  of  these  organisms  has 
satisfactorily  been  proven  to  be  specific.  In  the  nature  of  things  many 
organisms  will  be  found  in  any  gangrenous  process  about  the  mouth. 


188  DISEASES  OF   THE  ALIMENTARY   TRACT 

Lesions. — In  a  single  instance  I  have  seen  cancrum  oris  develop  in  a 
child  heforc  the  eruption  of  the  teeth.  In  all  other  ca.ses  my  experience 
confirms  Monti's  view  that  cancrum  oris  develops  from  a  previous 
ulcerative  stoiuatitis.  We  reo;ularly  find  the  margin  of  the  gums  over- 
lying several  teeth,  usually  the  molars,  dark  and  necrotic;  the  teeth  are 
loosened  or  have  already  fallen  out;  if  drawn,  the  roots  are  found  bathed 
with  a  thin,  greenish-l)lack  exudation,  which  gives  the  characteristic 
stench  of  gangrene,  'i'he  alveolar  ])roce.ss  is  softened  to  a  greater  or 
less  extent  and  the  destruction  may  extend  through  tiie  maxilla  and, 
if  in  the  upper  jaw,  involve  the  floor  of  the  nasal  passages  or  even  of 
the  orbit.  In  the  bone  the  disease  spreads  by  extension,  but  never 
seems  to  involve  the  palate  to  great  extent.  Some  writers  state  that  the 
process  never  attacks  both  sides  of  the  jaw,  but  in  my  experience  this 
is  not  so  uncommon.  The  most  striking  part  of  the  clinical  appear- 
ances, the  gangrene  of  the  soft  parts  of  the  face,  is  in  my  judgment  a 
secondary  process  and  is  a  true  gangrene.  The  margins  of  the  destroyed 
area  are  black  or  grayish  black,  ragged  and  sloughing.  The  discharge 
is  thin,  dark  greenish  black  in  color,  and  of  characteristic  odor.  There 
is  no  line  of  demarcation,  the  color  of  the  gangrenous  area  fading 
gradually  into  that  of  the  normal  skin. 

]\Iicroscopically,  in  the  margins  of  the  affected  area  sections  show  a 
zone  of  necrosis,  in  which  the  general  topography  of  the  tissues  can  still 
be  made  out  and  the  outlines  of  the  cells  are  seen,  but  the  cell  bodies 
stain  very  poorly  and  are  very  cloudy,  while  the  nuclei  have  entirely 
disappeared,  not  even  fragments  being  visible.  Occasionally  the  walls 
of  an  artery  on  the  margin  may  re^semble  a  normal  artery,  but  the 
vessel  is  blocked  l)y  a  thrombosis.  Beyond  the  area  of  cell-death  is  a 
narrow  zone  of  marked  infiltration  with  leukocytes.  On  the  boundary 
of  these  two  zones  and  in  the  area  of  infiltration  bacteria  of  various 
kinds  can  usually  be  demonstrated  by  appropriate  methods. 

As  to  the  nature  of  the  pathological  process  various  theories  have  been 
held.  By  some  it  is  regarded  as  simply  a  marantic  gangrene.  With 
that  idea  my  experience  is  not  in  harmony.  Among  the  hundreds  of 
cases  of  marasmus  seen  in  the  New  York  Foundling  Hospital  yearly, 
the  disease  is  practically  never  seen.  It  occurs  in  children  of  two  years 
or  more,  usually  well-nourished  previously,  l)ut  prostrated  by  some 
severe,  acute  illness.  Thrombosis  of  the  bloodvessels  has  been  held 
by  some  to  be  the  cause  of  the  disease,  but  a  little  study  soon  convinces 
one  that  the  thrombosis  is  a  secondary  phenomenon,  not  the  primary 
process.  Woronichin,  finding  some  slight  changes  in  the  nerves  in  the 
neighborhood  of  the  gangrenous  area  advanced  the  theory  of  a  causative 
"disturbed  enervation,"  but  the  distribution,  manner  of  extension,  and 
all  the  clinical  features  are  against  that  explanation.  Although  the 
specific  organism  has  not  yet  been  identified,  there  is  good  reason  to 
believe  that  the  disease  is  due  to  the  invasion  of  bacteria  in  a  tissue 
already  prepared  for  their  growth  by  a  severe  stomatitis  and  in  an 
individual  whose  powers  of  resistance  have  been  greatly  lowered  by 
acute  disea.se   (measles,   whooping-cough,   etc.). 


DISEASES  OF   THE  MOUTH   AXD   PHARYNX 


189 


Symptomatology. — The  disease  almost  always  begins  in  a  severe 
ulcerative  stomatitis.  The  gums  have  the  appearances  belonging  to 
that  affection.  About  the  bases  of  one  or  more  of  the  teeth  there  is  the 
characteristic  line  of  necrosis.  Salivation  is  present,  but  not  marked. 
The  first  sign  of  the  onset  of  gangrene  is  the  change  in  the  odor  of  the 
breath  and  saliva.  Instead  of  the  foul  odor  that  belongs  to  ulcerative 
stomatitis  we  get  the  horrible  stench  that  usually  accompanies  a  wet 
gangrene  of  any  part.  At  this  time  if  examination  is  made  we  find  the 
teeth  in  the  affected  area  loosened;  if  pulled  their  roots  are  found  bathed 
in  thin,  dark  fluid,  which  emits  the  characteristic  odor.  The  periosteum 
is  loosened  about  the  alveolar  process  and  there  may  be  some  superficial 


Fig.  36 


Noma.    (Schamberg.) 


necrosis  of  the  bone.  The  process  more  often  attacks  the  upper  jaw 
(Fig.  36j .  Within  twenty-four  to  forty-eight  hours  the  tissues  overlying 
the  affected  teeth  show  a  deep  bluish-green  color  underneath  the  skin, 
very  much  like  a  deep  bruise.  At  this  time,  also,  swelling  appears  and 
a  deep  induration  of  the  part  can  be  made  out.  Gradually  the  color  of 
the  area  deepens  until  there  is  a  small  circle  showing  the  characteristic 
greenish-black  hue  of  gangrene.  Meanwhile  there  is  a  further  separation 
of  the  periosteum  from  the  underlying  maxilla,  together  with  more 
superficial  necrosis  of  the  bone.  We  may  find  the  process  extending 
upon  the  bone  well  up  toward  the  orbit,  before  there  is  much  breaking 
down  of  the  skin.    The  sloughing  begins  in  the  centre  of  the  area,  first 


190 


DISHASfu'^  OF    THE   ALIMENTARY    TRACT 


appeariiit^;  upon  the  lip  or  cluH^k,  jiiul  once  l)ri:;iiii  oxtcMids  rapidly, 
destroying  the  whole  lip  or  cheek,  the  side  of  the  nose,  hiyintr  l)are  the 
l)ony  parts  heiieath,  and  producinii;  the  most  horrible  sii^ht  that  one  is 
called  upon  to  see.  With  the  involvement  of  the  cheek  there  is  an 
almost  constant  flow  of  saliva  from  the  corner  of  the  mouth,  bearing  with 
it  the  discharge  from  the  gangrenous  area.  The  odor  pervades  the 
whole  room  or  ward  and  is  very  sickening.  The  process  may  involve 
both  sides  (P^ig.  .'>7). 

The  general  condition  of  these  cases  varies  greatly.  In  some  instances, 
it  is  said,  the  children  do  not  appear  to  be  very  ill,  some  even  sitting 
up  in  betl,  apparently  undisturbed,  and  picking  out  the  loosened  teeth 


Noma.    (Schamberg.) 

or  bits  of  necrotic  tissue.  Usually,  however,  the  patients  are  markedly 
prostrated  from  the  beginning,  the  temperature  is  high — 102°  to  104°  Y. 
— and  tile  pulse  correspondingly  raj)id.  It  is  remarkable  that  there  is 
little  complaint  of  pain,  and  the  children  continue  to  take  nourishment 
fairly  well.  In  my  experience  the  disease  is  very  soon  complicated  by 
a  septic  bronchopneumonia,  wdiich  is  evidenced  by  a  higher  temperature 
— 105°  to  10(3°  F. — more  rapid  pulse  and  respiration,  greater  prostration, 
and,  if  the  child  lives  long  enough,  signs  of  areas  of  consolidation, 
particularly  in  the  1()W(M"  and  |)osterior  parts  of  the  lungs.  Death  usually 
occurs  from  exhaustion.  It  is  not  very  uncommon  to  find  an  extensive 
diphtheria  of  the  nasopharynx,  pharynx,  and  possibly  the  larynx  as  a 
terminal  complication. 


DISEASES  OF   THE  MOUTH   AND   PHARYNX  191 

Prognosis. — The  course  of  the  gangrene  is  usually  rapid,  terminating 
fatally  in  from  one  to  three  weeks.  Instances  of  spontaneous  recovery 
are  recorded.  In  these  a  line  of  demarcation  forms,  the  slough  separates, 
the  general  condition  improves,  and  recovery  ensues,  but  with  a  horrible 
deformity  from  the  destruction  of  the  soft  parts  of  the  face. 

From  70  to  90  per  cent,  of  all  cases  are  said  to  be  fatal.  I  have  never 
seen  but  one  case  get  well,  and  that  patient  had  lost  one-half  of  the  lower 
maxilla. 

Treatment.; — The  vital  point  in  this  regard  is  prevention.  The  careful, 
antiseptic  treatment  of  the  mouth  in  all  the  infectious  diseases  of  children, 
especially  measles,  is  essential.  The  appearance  of  ulceration  of  the 
gums  should  be  the  signal  for  increased  vigilance  and  active  treatment. 
The  ulcerated  area  should  be  scraped  clean  or  touched  with  nitric  acid, 
and  every  effort  should  be  made  to  strengthen  the  child  by  increased 
feeding  and  alcoholic  stimulants.  If  the  necrosis  of  the  gum  spreads  the 
loosened  teeth  should  be  removed,  and  the  necrotic  tissue,  bone  as  well 
as  soft  parts,  scraped  away.  It  is  by  these  methods  that  I  believe  the  dis- 
ease is  to  be  arrested.  When  the  process  has  once  involved  the  soft  parts 
the  chances  of  successful  treatment  are  reduced  to  a  minimum.  The 
application  of  caustics,  such  as  nitrate  of  silver,  chloride  of  zinc,  nitric 
acid,  is  often  advised,  but  they  are  practically  useless  and  should  be 
abandoned.  Valuable  time  is  lost  by  using  them.  The  gangrenous  area 
in  the  soft  tissue  should  be  destroyed  with  the  actual  cautery,  the  cauteri- 
zation being  carried  well  beyond  the  apparent  line  of  gangrene.  The 
underlying  bone  should  be  scraped  thoroughly,  teeth  being  removed,  and 
care  taken  that  no  foci  are  left  in  the  alveoli.  By  this  method  von  Raube, 
of  Berlin,  has  reported  a  number  of  successes,  and  Bainbridge  has  saved 
some  cases  in  the  New  York  City  Children's  Hospitals. 


DISEASES  OF  THE  PHARYNX. 
ACUTE  PHARYNGITIS. 

Acute  inflammation  of  the  pharynx  in  practice  includes  an  acute 
catarrhal  inflammation  of  the  pillars  of  the  fauces,  the  uvula,  tonsils, 
lateral  and  posterior  walls  of  the  pharynx.  It  is  quite  regularly  accom- 
panied by  a  similar  process  in  the  nasopharynx,  which  may  be  of  more 
importance  than  the  visible  lesions  of  the  pharynx.  It  may  be  preceded 
or  followed  by  similar  inflammation  of  the  nose  or  of  the  larynx,  trachea, 
and  bronchi. 

It  is  well  known  that  acute  inflammation  of  the  pharynx  occurs  as 
an  early  symptom  in  many  of  the  infectious  diseases,  especially  measles, 
scarlet  fever,  diphtheria,  and  influenza.  It  may  be  primary,  and  is  then 
most  often  due  to  exposure  to  cold  or  wet,  or  in  our  cities  to  exposure 
to  high  winds  laden  with  the  dust  and  dirt  of  the  streets,  or  to  digestive 
disorders.  It  may  be  the  beginning  of  what  is  so  commonly  designated 
as  a  "cold,"  the  explanation  of  which  is  probably  a  bacterial  infection. 


102  DISEASES  OF    THE   ALIMEXTAu'Y    TRACT 

and  tluMi  tlu'  inflammation  will  usually  extiMid  to  both  nose  and  tliroat,  or 
it  may  1)C'  simply  an  incident  of  acute  catarrlial  ])rocesse.s  hei^iinninL!;  in 
other  parts  of  the  respiratory  tract.  l'n(h)ul)tc(lly  it  is  more  common 
in  mouth  l)reathers,  especially  in  those  sufVerinfr  from  adenoids.  Certain 
children  seem  to  be  peculiarly  susceptible  and  have  repeated  attacks. 
These  are  commonly  explained  on  the  basis  of  rheumatism,  but  with 
verv  little  reason.  The  explanation  of  repeated  attacks  of  acute  j)haryn- 
geal  inflammation  will  much  more  often  be  found  to  be  mouth  brt'athing 
from  obstruction  in  the  nose  or  nasopharynx,  improper  feeding,  or  the 
persistent  use  of  too  warm  baths  by  which  resistance  to  exposure  to 
cold  is  lowered. 

Pathology — The  lesions  are  those  of  any  acute  inflammation  of  a 
mucous  membrane,  acute  congestion  and  swelling,  usually  with  some 
lessening  of  the  normal  mucous  .secretion.  I.,ater,  the  congestion  dis- 
appears, the  swelling  lessens,  the  mucous  membrane  becomes  relaxed, 
and  the  secretion  of  mucus  is  increa.sed.  Every  case  should  be  examined 
for  the  presence  of  adenoids  or  other  cause  of  ol)struction  of  the  nasal 
pa.ssages. 

Symptomatology  — The  affection  generally  begins  in  a  mild  way  with 
some  .soreness  of  the  throat,  difficulty  in  swallowing  or  actual  pain, 
especially  if  the  nasopharynx  is  involved,  and  slight  constitutional 
disturbance.  Usually  there  is  but  little,  if  any,  fever,  but  in  .some 
children  the  onset  will  be  acute,  .severe,  and  attended  with  high  temper- 
ature and  marked  prostration,  exactly  as  if  the  children  were  beginning 
an  acute  infectious  disea.se.  Inspection  shows  a  more  or  less  general 
injection  of  the  pharyngeal  ti.ssues,  which  are  often  dry  as  well  as  red, 
but  may  be  covered  with  nuicus.  The  cervical  lymph  nodes  may  be 
slightly  swollen.  If  the  temperature  is  rai.sed  there  is  a  corresponding 
cjuickening  of  the  pulse.  The  process  usually  sub.sides  gradually  after 
the  first  day,  but  may  for  a  day  or  two  increase  in  severity.  The  cour.se 
rarely  covers  more  than  four  or  five  days.  If  the  process  extends  it  is 
then  followed  by  an  acute  laryngitis  or  bronchitis,  which  may  be  of 
more  importance  than  the  inflammation  of  the  pharynx. 

Diagnosis. — Inspection  will  reveal  the  condition.  The  important  point 
is  to  be  sure  that  one  is  not  dealing  with  an  acute  infectious  di.sease. 
Naturally,  this  is  to  be  most  feared  in  the  ca.ses  with  high  temperature. 
In  a  family  of  children  it  is  a  good  practice  to  separate  a  suspicious  case 
until  the  question  can  be  satisfactorily  answered.  Scarlet  fever  will 
promptly  announce  it.self  by  the  eruption.  Measles  may  now  be  di.s- 
tinguished,  in  most  ca.ses  at  lea.st,  by  the  presence  or  al)sence  of  the 
Koplik  spots.  Cultures  .settle  the  possibility  of  diphtheria.  With  these 
questions  disposed  of,  the  affection  is  a  matter  of  a  few  days'  time. 

Treatment. — The  prophylaxis  has  been  sufficiently  indicated  in 
di.scussing  the  etiology.  Removal  of  obstructions  to  nasal  breathing 
and  correction  of  imj^roper  feeding  or  batiiing  habits  are  of  im|)ortance. 
The  affection  is  self-limited,  but  treatment  may  be  of  value  for  the 
patient's  comfort  or  to  prevent  the  extension  of  the  process  to  the  larynx 
and  bronchi.    The  children  should  remain  in-doors  and  a  mild  laxative 


DISEASES  OF   THE  MOUTH  AND  PHARYNX  193 

be  given.  For  most  children  the  milk  of  magnesia,  4.0-15  c.c.  (5j-iv), 
or  the  effervescing  citrate,  90-120  c.c.  (.^iij-iv),  answer  very  well.  Local 
applications  are  desirable,  but  young  children  so  often  resist  any  attempt 
in  that  direction  that  it  may  be  impossible  to  use  them.  Beneficial 
results  are  secured  in  these  cases  by  irrigating  the  pharynx  through  the 
nose  with  small  cjuantities  of  a  2  per  cent,  solution  of  boric  acid, 
normal  salt  solution,  or  a  1 : 4  solution  of  glycothymoline.  The  Berming- 
ham  douche  is  a  very  convenient  device  for  introducing  these  solutions, 
but  a  blunt-tipped  glass  syringe  or  even  a  teaspoon  will  answer  the 
purpose.  Such  irrigation  may  be  repeated  every  two  or  three  hours 
without  danger  to  the  Eustachian  tubes.  In  all  cases  where  irrigation 
is  called  for  it  is  necessary  to  consider  the  infection  and  congestion  of 
the  Eustachian  canals  that  may  be  associated  wdth  disease  of  the  naso- 
pharynx. Cracked  ice  may  be  given  to  be  held  in  the  mouth.  Cold 
compresses  applied  to  the  neck  and  renewed  every  hour  may  be  found 
useful.  The  diet  should  be  liquid  and  should  be  given  cold  or  but 
moderately  warm.  In  older  children  any  of  the  above  solutions  may  be 
used  as  a  gargle,  but  on  account  of  the  presence  of  inflammation  in  the 
nasopharynx  it  may  even  in  these  cases  be  desirable  to  introduce  the 
fluid  through  the  nose.  If  there  is  a  temperature  or  much  constitutional 
disturbance  small  doses  of  phenacetin,  0.130  gm.  (2  grains),  to  a  three- 
year-old  child  will  give  relief.  After  the  acute  symptoms  have  subsided 
the  affection  is  well  left  to  nature's  resources. 


SIMPLE  CHRONIC  PHARYNGITIS   (ELONGATION  OF  THE  UVULA). 

Simple  chronic  inflammation  of  the  pharynx  is  rarely  seen  in  child- 
hood, except  as  an  attendant  of  chronic  processes  in  the  nose  or  naso- 
pharynx. We  do,  however,  see  a  chronic  enlargement  and  elongation 
of  the  uvula  which  may  properly  be  considered  in  this  connection. 

Etiology. — This  condition  of  the  uvula  is  by  some  regarded  as  con- 
genital. More  commonly  it  seems  to  be  the  result  of  repeated  attacks 
of  acute  pharyngitis  produced  in  one  or  the  other  of  the  ways  already 
considered.  It  is  often  associated  wdth  chronic  hypertrophy  of  the 
tonsils. 

Symptomatology. — The  most  common  symptom  is  a  persistent  cough, 
a  cough  which  is  often  regarded  as  due  to  a  bronchitis  and  treated 
accordingly.  The  cough  is  especially  marked  when  the  child  is  lying 
down  or  sleeping.  In  some  cases  the  enlarged  uvula  may  give  difficulty 
in  sucking  or  swallowing.  Upon  inspection  the  elongated  uvula  is 
readily  seen  hanging  from  a  relaxed  palate  and  resting  upon  the  base 
of  the  tongue.  The  part  is  usually  pale  and  oedematous.  In  older 
children  the  condition  gives  rise  to  frequent  efforts  at  clearing  the 
throat,  "hacking,"  and  expectoration.  There  may  be  complaint  of 
soreness  of  the  throat  and  the  constant  efforts  at  relief  only  aggravate 
the  condition.  As  a  rare  condition  the  uvula  is  found  congenitally 
enlarged  and  bifid. 
13 


194  DISEASES  OF   THE  ALIMEXTARY    TRACT 

Treatment. — If  the  affection  is  associated  with  chronic  enlargement 
of  the  tonsils  or  the  presence  of  adenoid  vegetations  the  removal  of 
these  conditions  may  snffice  to  correct  the  condition  of  the  nvula.  In 
very  mild  cases  astringent  gargles,  such  as  0.")20-0.()r)0  gm.  (8  or  10 
grains)  of  alum  to  30  c.c.  (1  ounce)  of  water,  or  the  application  of  a 
2  per  cent,  solution  of  nitrate  of  silver,  may  be  tried.  In  marked  cases 
it  is  best  to  remove  the  uvula.  This  can  be  easily  done  by  grasping  the 
tip  with  a  pair  of  long  force})s  and  snipping  the  uvula  above  with  scissors, 
cutting  a  little  oblicjuely.  Care  should  be  taken  not  to  remove  too  much 
of  the  uvula,  as  free  hemorrhage  may  result.  It  is  to  be  remembered 
that  the  stump  may  be  very  painful  for  some  days  or  even  a  week  after 
the  operation. 


CHRONIC  FOLLICULAR  PHARYNGITIS. 

This  is  a  condition  of  chronic  iuHammation  of  the  small  masses  of 
lymphoid  tissue  normally  present  in  tlie  posterior  wall  of  the  pharynx. 
It  is  regularly  associated  with  chronic  enlargement  of  the  tonsils  and 
the  presence  of  adenoid  growths  in  the  nasopharynx.  It  may  be  as  an 
independent  condition  after  the  removal  of  tonsils  or  adenoids  or  in 
their  absence.  Its  etiology  and  pathology  are  essentially  those  of  these 
conditions.     It  is  seen  in  children  of  poor  vitality. 

Symptomatology. — In  most  cases  there  are  no  symptoms  at  all  referable 
to  the  pharyngeal  lesions,  and  they  are  discovered  by  accident  in  the 
course  of  examination  of  the  throat.  In  certain  cases,  however,  espe- 
cially after  exposure  to  cold  during  the  winter  months,  these  little  growths 
become  somewhat  swollen  and  congested,  and  may  then  give  rise  to 
discomfort,  a  sense  of  rawness  or  even  pain  in  the  throat,  and  hawking 
to  clear  the  throat.  The  appearances  are  characteristic.  The  little 
rounded  growths,  pale  or  reddish  in  color,  are  seen  projecting  slightly 
above  the  surface  of  the  pharyngeal  wall,  and  scattered  at  intervals 
over  it.  They  very  much  resemble  the  corresponding  lymphoid  masses 
at  the  base  of  the  tongue. 

Treatment. — If  adenoids  or  enlarged  tonsils  are  present  the  removal 
of  these  may  be  all  that  is  required.  The  pharyngeal  growths  rarely 
demand  removal.  If  it  be  necessary  this  is  best  accomplished  by  burning 
with  the  galvanocautery.  In  the  absence  of  this  the  growths  may  l)e 
cauterized  by  crystals  of  chromic  acid  fused  on  a  glass  rod.  Only  two 
or  three  points  should  be  touched  at  one  sitting  and  a  number  of  appli- 
cations may  be  required. 


AFFECTIONS  OF  THE  UVULA. 

The  uvula  is  commonly  considered  simply  as  one  of  the  structures 
involved  in  pathological  processes  of  the  throat  and  receives  no  special 
mention.    It  does,  however,  possess  a  certain  individuality.    It  may  be 


DISEASES  OF  THE  MOUTH  AND  PHARYNX  I95 

congenitally  short  or  absent,  bifid  or  abnormally  long.  The  latter  condi- 
tion may  be  a  factor  of  importance  in  the  production  of  chronic  cough 
or  even  asthma. 

In  acute  inflammation  of  the  throat  the  uvula  often  suffers  to  a  striking 
extent;  the  swelling  and  tenderness  of  this  part  not  infrequently  consti- 
tuting an  important  element  in  a  "sore  throat."  Huber,  of  New  York, 
has  reported  an  instance  illustrating  the  fact  that  the  uvula  alone  may 
be  involved  in  the  inflammation.  An  infant  ten  months  old  was  appar- 
ently well  until  two  hours  before  it  was  seen.  It  then  developed  a 
constant  irritating  cough,  accompanied  by  considerable  gagging.  A 
little  later  a  prominent  red  mass  was  observed  in  the  mouth.  There 
were  paroxysms  of  coughing  which  interfered  with  both  nursing  and 
deglutition.  The  general  symptoms  were  alarming  and  the  child  was 
in  considerable  distress.  On  examination  the  mass  in  the  mouth  was 
found  to  be  the  elongated  and  inflamed  uvula,  measuring  an  inch  in 
length  and  half  as  much  in  width.  It  was  red  and  edematous,  but  the 
throat  was  otherwise  normal.  The  symptoms  were  relieved  by  multiple 
needle  punctures  and  the  use  of  ice,  both  internally  and  externally. 
Chronic  hypertrophy  of  the  uvula  has  already  been  considered  under 
Chronic  Pharyngitis.  Nevus  of  the  uvula  is  sometimes  seen  and 
papilloma  may  occur. 


CHAPTER  X. 

DISEASES  OF  THE  STOMACH. 

THE  DIGESTIVE  ORGANS  AND  DIGESTION  IN  INFANCY 
AND  CHILDHOOD. 

BoTU  in  their  structure  and  functions  the  (Ugestive  organs  of  infants 
present  certain  peculiarities  which  serve  to  explain  to  some  extent  the 
qualitative  as  well  as  (|uantitative  differences  that  undoubtedly  exist 
between  infantile  and  adult  digestion.  The  more  important  of  these  it  is 
advisable  to  consider  as  a  preliminary  to  the  study  of  pathological 
conditions  affecting  these  organs. 

The  salivary  glands  are  present  at  birth,  and  are  functionally  active 
at  this  time.  The  digestive  power  of  their  secretion  has,  however,  long 
been  questioned  or  even  denied.  Although  previous  observers  had 
detected  ptyalin  in  the  saliva  of  newborn  infants,  Zweifel's  findings  that 
ptyalin  was  present  in  the  parotid  glands  at  birth,  but  not  in  the  sub- 
maxillaries until  after  the  second  month  have  long  stood  as  authoritative. 
Shilling  in  1903  proved,  however,  that  ptyalin  could  be  found  in  the 
submaxillaries  of  infants  from  nine  days  to  six  weeks  old.  Shaw,  of 
Albany,  has  recently  published  a  series  of  experiments  which  prove  that 
the  saliva  of  infants  possesses  some  diastatic  power  even  from  birth. 
The  investigations  of  Chittenden  have  also  shown  that  ptyalin  is  not, 
as  previously  supposed,  at  once  rendered  inert  by  mixture  with  the  acid 
contents  of  the  stomach,  but  that  its  action  continues  until  the  free 
hydrochloric  acid  reaches  one-tenth  of  1  per  cent.  While,  therefore, 
it  must  be  granted  that  the  saliva  of  infants  is  but  a  feeble  digestive 
agent,  it  does  possess  some  power,  a  power  which  partly  explains  the 
practical  experience  that  even  the  youngest  infants  can  at  times  take 
cereal  decoctions  with  advantage.  The  digestive  power  of  the  saliva 
rapidly  increases  during  infancy.  Korowin  was  unable  to  find  any 
difference  in  power  Ijetween  the  saliva  of  a  healthy  adult  and  that  of 
an  eleven-months-old  bal)v. 

The  Stomach. — At  birth  the  stomach  is  very  small,  its  cubic  capacity 
averaging  1  ounce,  and  it  often  appears  as  if  simply  a  dilated  portion  of 
the  intestinal  canal  rather  than  a  distinct  organ.  Its  rate  of  growth 
is,  however,  very  rapid.  At  three  months  its  average  capacity  is  four 
and  a  half  ounces,  at  six  months  six  ounces,  and  at  a  year  nine  ounces. 
The  walls  at  first  are  thin  and  especially  lacking  in  muscle  tissue, 
but  in  this  respect  also  growth  is  rapid.  It  is  often  said  that  in  early 
infancy  the  position  of  the  stomach  is  vertical,  and  that  the  organ  only 
gradually  assumes  the  horizontal  position  characteristic  of  later  life. 
(196) 


DISEASES  OF  THE   STOMACH  197 

To  a  certain  extent  such  statements  are  misleading.  The  stomach  in 
infancy  occupies  a  somewhat  more  upright  position  than  in  later  life, 
chiefly  owing  to  the  fact  that  the  fundus  is,  as  yet,  but  very  little 
developed,  but  it  is  never  vertical,  and  by  the  end  of  the  first  year  the 
position  is  practically  that  normal  in  later  years.  Microscopically, 
according  to  Baginsky,  the  differentiation  of  the  cells  of  the  mucous 
membrane  into  several  types  can  be  recognized  in  the  newborn. 

The  gastric  secretion  of  infants  in  health  is  a  rather  thick,  colorless, 
tenacious,  mucous  material  which  is  usually  strongly  acid  in  reaction, 
but  sometimes  neutral.  As  a  rule,  it  contains  free  hydrochloric  acid, 
but  not  always,  and  pepsin  or  pepsinogen.  Its  most  constant  and 
characteristic  constituent,  however,  is  the  so-called  lab-ferment,  which 
is  found  both  in  sick  and  in  well  children  and  at  all  stages  of  digestion. 
It  is  to  this  lab-ferment  that  the  prompt  coagulation  or  clotting  of  milk 
of  any  kind  which  takes  place  upon  its  introduction  into  the  stomach 
is  due.  This  clotting  takes  place  no  matter  what  the  reaction  of  the 
stomach  contents  and  entirely  independent  of  the  presence  or  absence 
of  free  hydrochloric  acid.  Whether  the  hydrochloric  acid  itself  exercises 
an  independent  influence  upon  this  process  of  clotting  is  not  known. 
It  is,  therefore,  to  the  presence  of  this  lab-ferment  that  the  most  striking 
difference  in  the  digestion  of  human  and  cows'  milk — the  well-known 
fine  clotting  of  the  one  in  contrast  to  the  thick,  tough,  almost  glutinous 
clots  formed  by  the  other — must  be  ascribed. 

To  the  hydrochloric  acid  is  ascribed  the  chief  role  in  the  gastric 
digestion  of  the  infant  (Unger).  The  secretion  of  this  acid  begins  with 
the  reception  of  food  and  continues  throughout  the  digestive  process, 
yet  it  is  often  impossible  to  demonstrate  the  presence  of  free  hydro- 
chloric acid  in  the  infant's  stomach  until  near  the  end  of  the  digestive 
process,  one  and  one-quarter  to  two  hours  after  feeding,  the  reason  for 
this  being  that  the  acid  as  it  is  secreted  is  taken  up  and  chemically  fixed 
by  the  albumins  and  salts  of  the  food,  and  only  when  the  affinities  of 
these  constituents  of  the  food  are  satisfied  does  free  acid  appear  in  the 
gastric  contents.  The  proportion  of  acid  found  in  the  infant's  stomach 
is  always  much  lower  than  that  of  the  adult  organ — 0.13  per  cent,  as 
against  1.5  per  cent,  to  3.2  per  cent.  (Leo). 

It  has  been  demonstrated  in  Heubner's  clinic  that  milks  of  various 
kinds  differ  in  their  ability  to  take  up  hydrochloric  acid  according  to 
their  content  of  albumin  and  salts.  Cows'  milk  is  said  to  take  up  most 
acid,  mares'  milk  less,  and  human  milk  least  of  all,  only  from  one-third 
to  one-half  the  amount  taken  up  by  cows'  milk  (Miller),  another  fact 
which  helps  to  explain  the  differences  in  digestibility. 

In  infants  fed  entirely  upon  milk,  lactic  acid  is  a  constant  constituent 
of  the  gastric  contents,  this  acid  having  its  origin  in  the  milk-sugar. 
That  lactic  acid  probably  exercises  some  influence  upon  digestion  is 
now  known ;  as  is  shown  by  the  easily  digested  mother's  milk,  where 
the  amount  of  milk-sugar  is  conducive  to  lactic  acid  formation. 

A  question  of  considerable  importance,  in  infantile  digestion,  espe- 
cially with  relation  to  the  diagnosis  of  conditions  of  pyloric  obstruction, 


198  DISEASES  OF   THE  ALIMENTARY   TRACT 

is  that  of  tlic  duration  of  the  stay  of  food  in  the  stomach.  That  the 
contents  of  tlic  stomach  pass  very  rapidly  into  the  (hiodenum  and  that 
the  stomach  may  be  empty  within  one-half  hour  of  a  nursing  in  a  young 
infant,  is  well  known.  Epstein  gives  one  and  one-half  hours  as  the 
maximum  time  for  the  evacuation  of  the  stomach  in  a  hreast-fed  child. 
Naturally,  as  the  size  of  the  stomach  increases  and  larger  (piantities  of 
food  are  taken,  the  food  remains  longer  in  the  stomach.  In  artificially 
fed  children,  especially  in  those  taking  cows'  milk,  there  is  an  appreciable 
prolongation  of  this  period.  Even  in  the  intervals  between  the  periods 
of  digestive  activity  the  stomach  is  not  entirely  empty.  In  the  resting 
organ  a  small  quantity  of  yellowish  fluid  will  be  found,  which  contains 
all  the  constituents  of  the  gastric  secretion  in  concentrated  form  and 
gives  the  biuret  reaction  (Unger). 

Concerning  the  extent  of  the  digestive  process  which  is  carried  on  in 
the  stomach  there  has  been  considerable  discordant  investigation.  It 
is  now  generally  agreed  that  only  a  partial  peptonization  of  the  milk 
occurs  in  the  stomach.  It  is  usually  accepted  that  this  peptonization  is 
accomplished  by  the  agency  of  the  hydrochloric  acid  and  pepsin,  but 
some  hold  that  the  lal)-ferment  exercises  a  distinct  power  in  this  direction, 
as  peptone  can  be  found  in  the  stomach  contents  before  there  is  sufficient 
acid  and  pepsin  to  explain  their  presence.  However  that  may  be,  we 
are  satisfied  that  the  function  of  the  stomach  is  largely  that  of  a  reservoir 
and  that  the  greater  part  of  digestion  is  conducted  in  the  small  intestine. 
Here  the  acid  gastric  contents  are  subjected  to  the  combined  action  of 
the  bile,  the  pancreatic  juice,  and  the  intestinal  secretion.  It  is  generally 
accepted  that  bile  is  relatively  more  abundant  and  more  effective  in  the 
infant  than  in  adults,  the  relatively  larger  liver  being  assumed  to  produce 
a  larger  quantity  of  bile.  There  are  no  diflferences,  so  far  as  known,  in 
the  action  of  the  bile  in  infancy  and  in  later  life.  The  pancreatic  secre- 
tion shows  both  trypsin  and  steapsin  at  birth,  but  the  amylopsin  has  been 
said  not  to  appear  until  the  second  month  of  life.  Moro  has,  however, 
recently  established  the  fact  that  it  is  present  in  the  newly  born.  Of 
the  powers  of  the  intestinal  secretion  in  infancy,  practically  nothing  is 
known.  In  the  intestine,  however,  the  partially  peptonized  proteids 
are  rendered  soluble  through  the  action  of  the  trypsin  especially,  and 
prepared  for  absorption.  The  fats  taken  in  are  split  by  the  pancreatic- 
juice  into  fatty  acids  and  glycerin,  and  these  acids  are  then  saponified 
by  the  action  of  the  bile,  the  result  being  a  fine  emulsion  of  fat  which 
is  readily  absorbed.  Sugars  are,  of  course,  absorbed  in  their  natural 
condition.  Starch,  if  present,  is  affected,  to  some  extent  at  least,  by 
the  saliva,  and  it  now  appears  is  subjected  to  further  digestion  by  the 
pancreatic  secretions.  Clinically,  it  has  been  established  beyond  doubt 
that  infants,  even  in  the  first  months,  may  take  and  digest  starch  in 
small  amounts.  Absorption  for  the  most  part  is  carried  on  by  the  small 
intestine,  to  a  much  less  degree  by  the  large  intestine.  For  this  reason 
disturbances  of  the  small  intestine  produce  diarrhea,  with  frequent 
watery  passages,  followed  by  rapid  wasting.  In  affections  of  the 
colon  alone  the  diarrhea  is  less  watery  and  the  wasting  is  much  less 


Fig.  3 


Fig.  A. 


Fig.  S. 


Fig.  1.— Normal  stool  of  breast-fed  infant      Smear.     X  1000. 

Fig.  2. — Normal  stool  of  bottle-fed.  infant. 

Fig.  3. — Threads  of  mucus  from  an  infant's  stool,  in  streptoeooeus  enteritis.  Stained 
according  to  Weigert-Escherich      X  1000.    (After  Hirsch.) 

Fig.  4. — Dysentery  bacilli.  Smear  from  a  small  clump  of  pus.  Stained  with  dilute 
carbolic  fuehsin.     X  1000. 

Fig.  5. — Purulent  portion  of  an  infant's  stool  in  a  ease  of  acute  colitis.  Details  as 
in  Fig.  3. 


DISEASES  OF   THE   STOMACH  199 

rapid.  When  the  intestinal  contents  are  delayed  in  their  transit  through 
the  canal,  absorption  goes  on  to  such  an  extent  that  the  feces  are  reduced 
to  dTv,  hard  masses,  which  are  moulded  into  scybala  by  the  peristaltic 
action  of  the  intestines. 

The  Feces. — The  normal  breast-fed  child  has  from  one  to  five  move- 
ments daily,  wliich  are  at  first  unformed,  thui,  bright  yellow,  smooth 
and  with  Httle  odor.  fSee  Plate  V.)  After  the  first  few  weeks  the  passages 
show  some  consistency,  but  otherwise  remain  the  same.  The  artificially 
fed  child  taking  cows'  milk,  usually  has  less  frequent  movements,  which 
are  somewhat  formed,  lighter  yellow  in  color,  not  so  smooth,  and  having 
a  more  or  less  pronounced  and  rather  offensive  odor.  In  either  case 
the  first  e\'idence  of  intestinal  disturbance  is  an  increased  number  of 
movements  which  are  first  of  all  looser  and  then  show  a  change  of  color, 
becoming  green.  Later,  the  movements  show  curds,  which  are  usually 
the  undigested  proteid,  and,  perhaps,  mucus  or  blood.  Pus  is  not  often 
visible  in  the  movements  of  children.  The  curds  are  usually  small, 
white  masses,  closely  resembling  those  seen  in  sour  milk,  but  fat  also 
may  present  itself  in  masses,  which  are,  however,  hght  yellow  in  color, 
more  translucent  and  oUy  in  appearance.  The  fatty  masses  are  readily 
soluble  in  alcohol  or  ether.  These  masses  of  fat  may  come  from  the 
food  or  from  cod-hver  oil  or  other  fat  administered  medicinally.  The 
oTeenish  color  so  characteristic  of  the  diarrheal  movements  of  children 
is  said  to  be  due  to  a  change  in  the  reaction  of  some  part  of  the  intestinal 
canal,  it  becoming  alkaline  instead  of  acid — for  in  the  normal  condition 
the  tract  is  said  to  have  an  acid  reaction  throughout.  Bacterial  action 
is  doubtless  concerned  in  the  change.  It  is  to  be  remembered  that  quite 
normal  stools  may,  upon  exposure  to  the  air,  shortly  show  a  greenish 
tinge  upon  the  surface. 


RECURRENT  VOMITING. 

Under  this  tide  is  indicated  an  affection  called  also  Periodic  or  Cyclic 
Vomiting,  first  described  by  Gee,  characterized  by  more  or  less  frequent 
attacks  of  severe  vomiting,  with  or  without  fever,  and  accompanied  by 
marked  prostration,  and  not  to  be  accounted  for  by  indiscretions  of 
diet,  organic  disease,  or  other  common  cause  of  such  disorders. 

Etiology. — The  aft'ection  is  not  usually  met  vdth  in  infancy,  but 
belongs  especially  to  children  from  six  to  twelve  years  of  age.  A  number 
of  cases,  have,  however,  been  met  with  in  children  not  over  three  years 
old.  Girls  are  said  to  be  attacked  more  often  than  boys.  A  gouty, 
rheumatic,  or  neurotic  family  histon,^  is  found  in  most  of  the  cases.  For 
a  long  time  the  exact  nature  of  the  affection  has  been  the  subject  of 
much  discussion,  the  weight  of  opinion  inclining  to  the  view  that  the 
disorder  was  not  dependent  upon  the  organic  disease  of  the  alimentary' 
tract,  or.  indeed,  of  any  organ,  but  was  rather  a  gastric  netu"osis.  Certain 
obser\,'ations  have  shown  that  during  the  attacks  there  is  a  marked 
diminution  in  the  excretion  of  uric  acid,  the  ratio  of  uric  acid  to  urea 


200  DISEASES  OF   THE  ALIMENTARY   TRACT 

present  in  the  urine  rising  from  a  normal  of  1  to  40  or  50  to  1  to  80, 
or  at  times  even  as  high  as  1  to  150.  These  observations  had  served  to 
connect  the  disorder  with  the  group  of  disturbances  attributed  to  that 
verv  vague  and  misatisfactorv  concHtion  known  as  the  uric  acid  diathesis. 

It  was  believetl  tiiat  the  underlying  condition  was  a  disturbance  of 
metabolism  resulting  in  a  diminished  excretion  of  uric  acid,  and  that 
these  attacks  of  vomiting  were  exactly  similar  to  the  attacks  of  migraine 
from  which  certain  individuals  sutler.  Recently,  attention  has  been 
calknl  to  the  fact  that  in  most  of  these  cases,  if  not  all,  the  attacks  are 
accompanied  by  the  presence  in  the  urine  of  those  products  of  imperfect 
metabolism,  acetone,  diacetic  acid,  and  /?-oxybutyric  acid  which  have 
been  found  in  the  urine  in  cases  of  diabetes.  The  original  observation 
of  Marfan  has  been  confirmed  in  this  comitry  by  the  work  of  Edsall, 
Pierson  and  others.  The  exact  significance  of  these  observations  with 
relation  to  the  underlying  process  is  not  yet  clear.  It  may  be  that  the 
real  cause  of  the  disturbance  is  error  in  the  internal  metabolism  of  the 
tissues  similar  to  that  present  in  diabetes.  Edsall  inclines  to  the  view 
that  the  primary  disturbance  is  one  of  digestion,  and  that  careful  observa- 
tion will  show  some  irregularities  of  digestion  preceding  the  attacks.  For 
the  present  we  can,  therefore,  only  say  that  most  of  these  cases  show 
the  condition  known  as  an  acid  intoxication  dependent  either  upon  an 
error  of  digestion  or  of  the  internal  metabolism.  It  is  not  at  all  probable 
that  all  cases  of  this  disorder  can  be  accounted  for  upon  this  one  basis, 
but  that  careful  study  will  show  some  other  cause  or  causes  for  at  least  a 
minor  portion  of  the  cases.  The  affection  is  not  a  frequent  one  and  in 
any  suspected  case  care  must  be  exercised  not  to  overlook  organic  lesions 
or  other  definite  cause  of  the  attacks. 

Symptomatology. — The  onset  of  the  attacks  is  usually  sudden,  and  is 
not  accounted  for  by  dietary  indiscretions.  It  w^as  formerly  asserted 
that  there  were  no  prodromata,  but  more  careful  observation  has 
shown  that  the  children  do,  for  at  least  a  day  or  two  before  each  attack, 
show  some  indisposition.  This  may  l)e  limited  to  an  appearance  of 
peevishness  or  listlessness  with  dark  lines  under  the  eyes  and  loss  of 
appetite.  In  other  cases  there  is  a  slight  fever — 100°  to  101°  F. — or  the 
movements  of  the  bowels  become  notably  pale  or  white.  Looseness  of 
the  bowels  may  be  associated  with  the  onset,  but  the  opposite  condition 
is  more  frequent.  Undoubtedly  in  some  cases  the  attacks  occur  in 
children  in  apparently  perfect  health. 

The  vomiting  once  begun  is  frequent  and  persistent.  Pierson  reports 
the  case  of  a  child  who  in  one  attack  vomited  eighty-seven  times  in  forty- 
four  hours  and  in  another  fifty-two  times  in  thirty-seven  hours.  The 
.stomach  is  intolerant  of  anything  and  every  attempt  at  medication  or 
feeding  by  that  route  results  in  a  repetition  of  the  vomiting.  All  the 
natural  consetjuences  of  such  a  disturbance  follow  in  due  course.  The 
eyes  become  sunken,  the  tongue  is  coated,  the  skin  dry,  the  abdomen 
is  retracted,  the  urine  is  scanty  and  high-colored  and  has  a  characteristic 
sweetish  oflor,  weight  is  lost  rapidly  and  the  prostration  becomes  extreme 
and  the  bowels  are  usually  constipated.    The  temperature  usually  rises 


DISEASES  OF   THE  STOMACH  201 

and  may  reach  103°  or  even  104°  F.  during  the  attack.  Each  attack  lasts 
for  two  or  three  days  and  is  regularly  followed  by  a  gradual  return  to 
normal.  It  may  be  weeks  before  the  child  recovers  from  the  prostration 
of  an  attack. 

The  periodicity  of  the  attacks  is  very  irregular.  They  usually  recur 
at  intervals  of  weeks  or  months.  Until  the  observations  upon  the 
presence  of  acetone  and  its  congeners  in  the  urine  were  made  there  was 
no  clear  explanation  of  the  recurrence.  It  now  seems  that  by  watching 
the  urine  for  the  appearance  of  these  bodies  the  advent  of  an  attack 
can  be  foretold  and  provided  for  or  even  prevented.  In  most  of  the 
cases  heretofore  reported  the  persistence  of  the  affection  has  been 
marked. 

Diagnosis.— In  a  first  attack  this  may  present  some  difficulties.  The 
natural  supposition  at  first  sight  would  be  that  the  child  was  suffering 
from  having  eaten  some  undigestible  food,  but  this  can  be  readily  ex- 
cluded by  the  history  of  the  case,  and  the  course  of  the  affection,  the 
complete  intolerance  of  the  stomach  for  a  period  of  several  days  followed 
by  prompt  recovery  being  cpiite  characteristic.  In  infants  pyloric 
.stenosis  should  not  be  overlooked  as  a  cause.  Meningitis  can  be 
excluded  by  the  absence  of  any  of  the  focal  symptoms  of  that  affection. 
The  urine  should  be  carefully  watched  to  exclude  the  possibility  of 
nephritis,  and,  in  the  light  of  our  present  knowledge,  tested  for  the 
presence  of  acetone. 

Tests  for  Acetone.  LegaVs  Test. — This  test  may  be  applied  to  the 
freshly  voided  urine,  but  it  is  much  better  to  first  distill  the  urine.  The 
test  solution  is  made  by  dissolving  a  few  crystals  (0.015-0.020  gm.  =  2  or 
3  grains)  of  sodium  nitroprusside  in  a  few  cubic  centimetres  of  water,  to 
which  are  added  a  few  drops  of  a  40  per  cent,  solution  of  sodium  hydrate. 
When  2  or  3  c.c.  of  urine  are  added  to  such  a  solution  a  red  color  develops, 
which,  in  the  presence  of  acetone,  is  replaced  by  a  purple  or  violet-red 
color  on  the  addition  of  a  few  drops  of  acetic  acid. 

Lieben's  Test. — This  and  the  following  (Reynolds')  are  both  applicable 
only  to  the  distilled  urine.  A  few  cubic  centimetres  of  the  distillate  are 
treated  with  several  drops  of  a  dilute  solution  of  iodopotassic  iodide 
and  sodium  hydrate  (easiest  made  by  adding  a  few  drops  of  the  40  per 
cent,  or  other  strong  sodium  hydrate  solution  to  a  dilute  Gram's  solution), 
when  in  the  presence  of  acetone  a  precipitation  of  iodoform  in  crystals 
occurs,  which  at  once  is  recognizable  by  the  yellow  color  and  charac- 
teristic odor. 

Reynolds'  Test. — A  few  cubic  centimetres  of  the  distillate  are  treated 
with  a  small  amount  of  freshly  precipitated  yellow  oxide  of  mercury. 
This  is  prepared  by  precipitating  a  solution  of  bichloride  of  mercury  with 
an  alcoholic  solution  of  sodium  hydrate.  If  acetone  be  present  a  black 
color,  due  to  the  formation  of  sulphide  of  mercury,  will  result  in  the  clear 
filtrate  upon  the  addition  of  a  few  drops  of  ammonium  sulphide.  In 
making  the  above  tests  it  is  always  best  to  use  freshly  prepared  solutions, 
but  inasmuch  as  the  reactions  are  qualitative  only,  it  is  not  necessary 
to  have  mathematically  accurate  solutions. 


202  DISEASES  OF  THE  ALIMEXTARY  TRACT 

It  is  to  be  remembered  that  acetone  is  found  in  the  urine  in  a  number 
of  other  concHtions,  notably  in  (Halx'tes,  where  its  occurrence  in  con- 
siderable (juantities  in  association  with  sut^ar  may  be  said  to  be  diag- 
nostic, and  when  also  the  amount  of  acetone  is  in  j)r()j)()rtion  to  the 
severity  of  the  disease.  Acetone  has  also  been  observetl  in  the  urine 
in  typhoid,  pneumonia,  scarlatina,  measles,  acute  miliary  tuberculosis, 
acute  articular  rheumatism,  and  septicemia. 

Prognosis. — So  far  as  the  individual  attack  is  concerned  the  prognosis 
is  generally  good.  (Irifhth  has,  however,  seen  two  c-ases  result  fatally, 
and  the  extreme  exhaustion  of  the  little  patients  makes  the  affection 
a  grave  one  in  most  cases.  As  above  stated  the  attacks  tend  to  recur 
with  marked  persistency  antl  there  seems  little  tendency  to  cure  without 
proper  tnnitment.  The  patients  may,  however,  maintain  their  nutrition 
well  and  otherwise  appear  to  enjoy  good  health. 

Treatment. — The  attacks  themselves  are  .self-limited  and  for  evident 
reasons  treatment  after  an  attack  is  once  established  is  difficult  and  not 
likely  to  be  very  effective.  Evidently  the  desirable  thing  is  to  get  at  the 
underlying  condition  and  prevent  the  recurrence  of  the  attacks.  In  the 
light  of  our  present  knowledge  of  these  acid  intoxications  the  control 
of  the  diet  is  of  the  utmost  importance.  As  it  is  apparently  the  carbo- 
hydrate digestion  or  metabolism  that  is  at  fault,  foods  of  this  class 
must  be  reduced  to  a  minimum.  Fats  also  are  said  to  be  poorly  borne 
except  in  the  form  of  fresh  butter  and  we  are  therefore  reduced  to  a 
dietary  consisting  in  great  part  of  nitrogenous  foods  with  green  vege- 
tables and  stale  bread  or  rusks.  Exactly  as  in  diabetes  it  is  rarely  of 
advantage  to  entirely  forbid  the  use  of  carbohydrate  foods,  .so  in  this 
disorder  they  should  not  be  entirely  excluded,  but  limited  to  small 
quantities. 

Working  on  these  lines  a  dietary  for  a  child  six  years  of  age  might 
be  constructed  as  follows: 

BreaJxfasf. — Eight  to  twelve  ounces  of  fresh  milk;  one  or  two  table- 
spoonfuls  of  a  wheaten  cereal  with  milk;  dry  toast  or  zwieback  or  rusk 
with  butter;  a  soft-boiled  egg,  or  occasionally  fresh  fish. 

Dinner. — Broth  or  soup  (clear);  a  chop,  bit  of  steak  or  roast  Ijcef, 
without  fat;  spinach,  celery  (stewed),  string-beans,  or  green  peas;  stale 
bread  and  butter;  milk,  if  desired. 

Supper. — Eight  or  twelve  ounces  of  milk;  a  bit  of  chicken,  or  fish 
(boiled),  or  occasionally  an  egg  (boiled);  dry  toast,  or  rusk,  or  zwieback, 
and  butter. 

Sugar  and  sweets  should  be  rigidly  excluded. 

Additions  to  the  dietary  should  be  made  with  care.  Dieting  on  such 
lines  will  .serve  to  greatly  reduce  the  fre(|uency  of  the  attacks.  Since 
the  discovery  of  the  condition  of  acid  intoxication  in  the.se  cases  the 
continuous  administration  of  sodium  bicarbonate  in  quantities  sufficient 
to  neutralize  the  urine,  0.G5  gm.  (10  grains)  or  more,  three  times  a  day, 
has  been  found  extremely  useful.  By  these  means  the  recurrence  of 
the  attacks  has  been  completely  interrupted  in  a  number  of  cases. 
The  general  hygiene  of  the  patient  nmst  be  careil  for. 


DISEASES  OF    THE   STOMACH  203 

If,  in  spite  of  such  measures  or  in  their  absence,  an  attack  seems 
imminent,  but  is  not  yet  fully  developed,  the  administration  of  sodium 
bicarbonate  in  full  doses  as  much  asS.O  gm.  (2  drachms)  being  given  in 
divided  doses  during  a  day,  seems  capable  of  mitigating  the  severity  of 
an  attack,  or  even  checking  it.  Such  large  doses  of  the  alkali  should, 
naturally,  not  be  continued  for  many  days,  but  may  be  safely  persisted 
in  until  the  urine  is  quite  alkaline,  and  the  attack  is  over. 

With  a  rheumatic  record  the  use  of  soda  salicylate  is  advisable.  In 
all  cases  water  should  be  given  freely  and  the  bowels  kept  open. 

In  case  the  patient  is  already  vomiting  severely,  it  will  be  best  to  stop 
all  attempt  at  medication  or  feeding  by  the  mouth,  remembering  that 
the  attacks  usually  terminate  at  the  end  of  two  or  three  days.  Ice  may 
be  allowed,  to  suck,  or  water  given  in  teaspoonful  doses,  if  it  does  not 
bring  on  vomiting.  When  several  hours  have  passed  without  vomiting 
the  administration  of  food  may  be  begun  in  similar  minute  quantities, 
whey  or  broths  being  preferable  to  milk.  A  teaspoonful  may  be  given 
every  fifteen  or  thirty  minutes  in  the  beginning,  the  c|uantities  and 
intervals  being  both  gradually  increased.  Later,  kumyss,  matzoon,  ecjual 
parts  of  milk  and  lime-water  or  milk  and  Vichy  water  may  be  used. 
During:  the  heig-ht  of  an  attack  the  sodium  bicarbonate  or  other  necessary 
medication  mav  be  given  bv  the  rectum,  but  the  stomach  had  best  be 
spared  the  administration  of  any  medicine.  In  desperate  cases  morphine 
may  be  given  hypodermically,  but  only  to  tide  over  an  emergency.  In 
the  light  of  our  present  knowledge  the  subcutaneous  or  intravenous 
administration  of  a  feeble  solution  of  sodimn  bicarbonate  might  be  of 
help  in  a  critical  case,  but  so  far  as  known  this  has  not  yet  been  resorted 
to.  From  what  we  have  seen  of  the  use  of  such  solutions  in  diabetic 
coma,  we  know  that  this  treatment  can  be  safely  employed  in  conditions 
requiring  it,  but  any  such  painful  treatment  is  a  much  more  serious 
undertaking  in  a  child  than  in  an  adult. 


GASTRALGIA. 

The  term  gastralgia  may  be  applied  to  any  pain  in  or  referred  to  the 
stomach.  Practically,  however,  we  employ  it  to  cover  attacks  of  pain 
referred  to  the  stomach  and  not  accountable  for  by  definite  lesion  or 
disturbance  either  of  the  stomach  or  other  viscera.  The  clinical  con- 
ception is,  therefore,  of  a  sensor\'  neurosis  of  the  gastric  nerves — a 
neuralgia.  The  etiologv  of  such  a  nerve  disturbance  must  be  that 
of  a  neuralgia  affecting  any  other  nerve  of  the  body,  but  referred  to  the 
gastric  nerv^es  for  reasons  quite  beyond  our  present  knowledge.  It  may, 
therefore,  be  conceivably  produced  by  a  condition  of  nervous  exhaustion, 
by  a  gouty  or  rheumatic  disposition,  by  anemia,  or  by  whatever  other 
influences  may  impair  the  nutrition  or  function  of  the  nerves.  The 
more  carefully  we  try  to  understand  just  what  is  meant  by  a  neuralgia 
of  the  gastric  nerves  the  more  restricted  will  become  the  field  for  the 
application  of  the  term. 


204  DISEASES  OF   THE  ALIMENTARY   TRACT 

Pathology. — Of  the  changes  in  the  nerves  in  prastralgia  we  at  present 
know  nothing.  The  conchtion  in  the  other  parts  of  the  body  would 
be  that  of   some  one  of   the  general  conditions  above  suggested. 

Symptomatology. — In  a  true  gastralgia  the  pain  conies  in  attacks  of 
greater  or  less  severity  and  lasts  for  a  varying  length  of  time,  a  few 
minutes  or  hours.  The  onset  of  the  pain  is  sudden,  usually  severe,  and 
the  patient  may  be  fjuite  prostrated  by  the  attack,  but  recovers  promptly 
upon  the  remission  of  the  pain.  The  attacks  of  pain  have  no  relation  to 
the  taking  of  food,  and  pressure  upon  the  epigastrium  may  be  grateful 
rather  than  distressing.  If  the  pain  is  severe  vomiting  may  be 
excited,  but  this  is  generally  absent.  There  is  no  disturbance  of  pulse, 
respiration,  or  temperature,  and  the  general  health  of  the  individual 
may  lie  good. 

Diagnosis. — This  is  the  essential  point  in  reference  to  this  affection. 
The  common  error  is  to  loosely  speak  of  a  gastralgia,  when  more  careful 
ol)servation  would  show  that  the  supposed  neuralgia  isto  be  satisfactorily 
explained  by  some  lesion  of  the  stomach  or  neighljoring  organs.  It  is 
a  familiar  fact  that  young  children  will,  when  asked  "Where  is  the 
pain?"  promptly  lay  the  hand  upon  the  epigastrium,  when  the  physical 
examination  shows  that  the  lesion  is  in  the  lung,  the  pleura,  the  heart, 
the  appendix,  or  even  the  spine,  and  in  those  of  more  advanced  years 
the  seat  of  pain  may  not  lie  a  safe  guide  as  to  the  location  of  the  disease. 
Anv  complaint  of  persistent  or  recurrent  j)ain  in  the  gastric  region  should 
call  for  a  careful  study  of  the  case  and  a  thorough  physical  examination. 
The  historv  of  the  case  and  the  absence  of  any  marked  disturbance  of  the 
temperature,  pulse,  or  respiration  should  enable  us  at  once  to  exclude 
all  acute  inHannnatory  or  suppurative  conditions  of  the  stomach  or 
neio^hboring  viscera.  We  should,  then,  consider  the  possibility  of  the 
presence  of  some  chronic  disorder  of  the  gastroenteric  tract,  of  which 
we  should  expect  evidence  in  the  condition  of  the  breath  and  tongue,  tlis- 
turbance  of  the  appetite,  vomiting,  constipation  or  diarrhea,  and  the  like. 

A  careful  phvsical  examination  should  then  exclude  the  presence  of 
any  disorder  of  the  heart,  lungs,  liver,  or  spleen  which  might  account 
for  the  pain.  Enlargement  of  the  spleen  from  malaria  or  other  cause 
is  one  of  the  rarer  causes  of  epigastric  pain  in  children.  The  urine 
should  be  examined  to  exclude  ilisease  of  the  kidney  and  the  position 
of  those  organs  taken  into  account.  Finally,  the  spine  of  the  child 
should  be  carefully  examined  for  deformity,  rigidity,  or  other  sign  of 
beginning  disease  of  the  vertebrae.  The  orthopedic  surgeon  is  familiar 
with  cases  of  Pott's  disease  that  have  been  treated  for  weeks  or  even 
months  for  gastralgia  or  indigestion,  when  an  examination  of  the  spine 
would  at  once  have  disclosed  the  seat  of  real  trouble  and  rendered 
proper  treatment  possible  at  the  time  when  it  is  of  the  utmost  importance. 
Onlv  when  we  have  thus  gone  over  a  case  thoroughly  and  excluded 
everv  other  possible  cause  for  the  pain  may  we  safely  s])eak  of  a  gastralgia 
in  a  child. 

Treatment. — For  the  attacks  of  pain  relief  may  be  secured  by  putting 
the  patient  to  bed  and  applying  a  hot-water  bag  to  the  epigastrium. 


DISEASES  OF   THE   STOMACH  205 

More  effective  still  is  the  application  of  a  mustard  paste  or  turpentine 
stupes  to  the  epigastrium.  The  former  is  much  easier  of  application. 
Internally  0.60-2.0  c.c.  (about  10  to  30  drops)  of  brandy  or  gin  in 
hot  water  or  a  few  drops  of  spirits  of  chloroform  or  camphor  in  a 
teaspoonful  of  cold  water  will  be  effective.  The  more  important  problem 
in  chronic  cases  is  the  prevention  of  the  attacks.  If  we  can  get  at  a 
definite  cause  for  the  complaint,  rheumatic  or  gouty  diathesis,  anemia 
or  the  like,  the  proper  line  of  treatment  should  be  followed.  In  the 
absence  of  such  indication  the  diet  should  be  carefully  regulated  to  the 
end  of  improving  nutrition,  overexercise  forbidden,  and  adequate  rest 
secured.  The  systematic  use  of  Fowler's  solution,  begun  with  0.065  c.c. 
(1  drop)  given  well  diluted  in  water  and  increased  gradually  to  the 
limit  of  tolerance,  will  be  found  of  advantage.  It  is  much  better  to  give 
the  arsenic  in  this  way  than  in  a  complex  prescription,  for  increases  can 
be  made  more  readily  and  a  larger  amount  will  be  borne  without  disturb- 
ance. In  persistent  cases  an  out-of-door  life  in  the  country  may  be 
effective  where  other  remedies  have  failed. 


ACUTE  GASTRIC  INDIGESTION. 

The  line  between  the  condition  designated  as  acute  gastric  indigestion 
and  an  acute  gastritis  is  purely  theoretical,  yet  for  practical  purposes  it 
seems  advisable  to  describe  the  affections  separately. 

Etiology. — An  attack  of  acute  gastric  indigestion  may  be  brought  on 
at  any  time  when  an  unusual  tax  is  put  upon  the  stomach.  This  may 
arise  either  from  errors  in  the  quantity  or  quality  of  the  food  taken  or 
from  other  conditions  which  have  indirectly  lowered  the  functional 
activity  of  the  stomach  and,  perhaps,  rendered  it  unequal  to  demands 
which  it  had  previously  been  meeting  perfectly  well.  In  infants  such 
attacks  are  commonly  brought  on  either  by  feeding  too  much  at  one  time, 
or  by  sudden  changes  in  the  feeding,  such  as  weaning,  or  substituting  one 
food  for  another,  especially  if  the  new  food  be  cows'  milk,  giving  solid 
food  too  early,  etc.  Some  infants  show  such  a  susceptibility  to  cows'  milk 
that  the  giving  of  even  a  single  spoonful  may  be  sufficient  to  bring  on  a 
violent  attack  of  gastric  indigestion.     Fortunately,  such  cases  are  rare. 

In  children  the  errors  most  often  lie  in  overindulgence  in  pastry, 
candies  and  the  like,  or  too  hurried  eating.  Decayed  teeth  may  be  a 
cause  by  making  mastication  painful.  Unless  carefully  watched  and 
trained  many  children  habitually  eat  too  rapidly,  the  food  is  conse- 
quently imperfectly  masticated,  digestion  is  rendered  more  difficult  and 
upon  very  slight  occasion  may  be  entirely  arrested. 

Of  the  influences  which  bring  on  indigestion  through  impairment  of 
the  stomach  functions  the  most  important  are  dentition,  exposure  to 
unusual  cold  or  heat,  violent  exercise  immediately  after  eating,  or  great 
nervous  excitement. 

Pathology. — Of  this  we  can  naturally  know  nothing  directly,  but  it 
may  reasonably  be  assumed  that  in  this  condition  there  is  a  sudden 


206  DISEASES  OF  THE  AUMEXTARY   TRACT 

arrest  of  the  functions  of  the  stomach,  both  as  to  secretion  and  motion. 
Tlie  normal  ijjastric  juice  and  the  peristaltic  action  both  fail. 

Symptomatology. — An  attack  of  acute  gastric  indigestion  is  most  often 
inaugurated  by  more  or  less  abdominal  discomfort,  associated  with 
nausea,  and  followed  by  vomiting.  The  appetite  is  lost  and  the  tongue 
coated.  The  pain  may  be  severe.  The  vomiting  is  usually  violent  and 
is  prolonged  for  some  hours,  but  is  over  after  a  period  of  sleep.  The 
vomitus  shows  that  undigested  food  has  l)een  present  in  the  stomach 
many  hours  after  the  normal  length  of  time,  the  retention  being  due  to 
the  failure  of  the  motile  power  of  the  stomach.  The  general  symptoms 
which  are  attendant  upon  tliese  attacks  of  indigestion  are  important. 
In  the  milder  cases  there  may  be  none.  Often  there  is  more  or  less 
temperature— 100°  to  102°  F.— it  maybe  104°  or  105°  F.,  a  rapid  pulse, 
and  marked  prostration.  The  nervous  symptoms  may  be  marked  or 
even  alarming.  In  some  instances  the  child  is  listless,  stupid,  the  pupils 
contracted,  the  condition  suggesting  opium  poisoning.  In  other  cases 
the  child  is  restless,  excited,  and  convulsions  may  occur.  The  bowels 
are  usually  constipated,  but  this  soon  gives  way  to  a  diarrhea  with  the 
passage  of  much  undigested  food.  When  the  stomach  has  been  well 
emptied  the  disturbance  gradually  subsides.  The  temperature  and 
pulse  fall,  the  mental  condition  becomes  more  natural  and  recovery  is 
usually  prompt.  There  is  a  tendency  to  nausea  and  vomiting,  however, 
for  some  days  thereafter.  These  attacks  are  usually  not  serious  except 
in  feeble  infants,  in  whom  such  a  disturbance  may  well  prove  fatal.  In 
the  summer  season  every  such  attack  is  of  great  importance,  because  it 
opens  the  way  to  more  serious  disturbances  of  the  digestive  organs. 

Diagnosis, — This  is  not  difficult,  as  a  rule.  These  gastric  disturbances 
are  among  the  common  phenomena  of  infancy  and  childhood.  The 
history  of  the  case  usually  points  clearly  to  the  nature  of  the  affection, 
and  the  symptoms  are  straightforward.  One  may  not,  however,  be 
able  to  say  in  the  beginning  whether  the  disturbance  is  a  simple  indi- 
gestion or  a  gastritis,  nor  can  he  be  sure  that  the  symptoms  are  not 
those  that  mark  the  onset  of  some  acute  infectious  disease.  Time  will 
be  required  to  clear  up  the  latter  question. 

Prognosis. — -This  is  almost  always  good  except  in  the  case  of  weak 
infants,  to  whom  such  an  attack  may  be  fatal,  especially  if  the  nervous 
symptoms  are  severe  and  convulsions  occur. 

Treatment. — The  natural  course  of  the  disease  indicates  the  proper 
treatment,  emptying  the  stomach  and  rest  for  that  organ.  In  infants 
this  can  best  be  accomplished  in  the  manner  in  which  stomach  washing 
is  done  in  an  adult.  For  a  stomach  tube  one  uses  a  large-sized  rubber 
male  catheter,  size  16  American  or  24  French.  This  is  joined  by  a  bit 
of  glass  tubing  (to  allow  inspection  of  the  movement  and  character  of 
the  fluid  passing)  to  about  two  feet  of  small  ru))ber  tu])ing  connected  with 
a  glass  or  har<l-rnbl)er  funnel  capable  of  holding  125-175  c.c.  (4-0  oz.). 
The  child  should  be  carefully  wrapped  in  a  sheet,  with  the  arms  at  the 
sides,  so  as  to  prevent  it  from  grasping  the  tube,  and  then  held  face 
upward  on  the  nurse's  lap.    The  tube  can  be  easily  passed  through  the 


DISEASES  OF   THE   STOMACH 


207 


mouth  and  pharvnx  into  the  esophagus  (Fig.  38).  The  tube  should 
be  passed  over  the  laryngeal  region  as  rapidly  as  possible  to  avoid 
gagging.  Except  in  a  comatose  child  it  is  impossible  to  pass  the  tube 
into  the  larsmx.  It  is  well  to  measure  the  distance  from  the  tip  of  the 
ensiform  cartilage  to  the  chin,  beforehand,  as  a  guide  to  the  length  of 


Fig.  38 


Method  of  washing  out  the  stomach.    Xote  the  manner  of  holding  the  child  and  the  elevation 

of  the  funnel. 


tube  to  be  introduced,  although  there  Is  no  danger  of  passing  the  tube 
too  far.  Once  the  tube  is  in  the  stomach  the  funnel  is  raised  to  allow  the 
escape  of  gas,  then  lowered  to  siphon  out  the  contents  of  the  stomach. 
If  the  child  is  quiet,  nothing  is  likely  to  run  at  first,  but  if  a  few  ounces 
of  water  are  run  in  to  fill  the  tube  and  start  the  siphon  action,  the 


208  DISEASES  OF   THE  ALIMESTARY   TRACT 

stomach  will  be  promptly  emptied.  Water  should  then  be  used  until 
the  stomach  wjushinojs  are  clear.  If  the  siphon  will  not  work,  we  may 
be  sure  that  the  tube  ha.s  been  blocked  by  some  solid  food  stickinfi^  in 
the  eye  of  the  catheter.  In  that  cjise  the  tul)e  nuist  be  withdrawn, 
cleared,  and  replaced,  although  sometimes  running  in  a  little  more 
water  may  suffice  to  dislodge  the  obstruction.  Plain  water  at  a  temper- 
ature of  100°  F.  may  be  used,  or  normal  salt  solution,  or  sodium  bicar- 
bonate solution,  4  gm.  to  500.0  c.c.  (1  drachm  to  the  pint)  may  be 
emj)l()yed.  Many  authors  recommend  boric  acid  in  the  proportion  of 
1  :  200,  or  even  resorcin  1  :  oOOO;  but  as  cleansing  is  the  important  point, 
and  this  is  accomplished  best  by  the  alkaline  solution,  the  use  of  anti- 
septics has  nothing  to  recommend  it.  It  is  well  to  use  a  warm  solution. 
Collap.se  can  be  produced  or  augmented  by  cold  solutions. 

In  children  over  two  years  of  age  the  stomach  tube  cannot  ordinarily 
be  employed,  because  of  their  struggling  and  their  ability  to  bite.  We 
must  then  content  ourselves  with  giving  them  large  draughts  of  water 
with  4.0  to  8.0  c.c.  (1  to  2  dr.)  of  the  syrup  of  ipecac,  to  excite  active 
vomiting.  This  is  not  .so  satisfactory  as  the  stomach  washing,  but  we 
have  to  be  content  with  it. 

The  stomach  having  been  well  emptied,  nothing  but  water  should 
be  given  for  several  hours.  If  the  attack  occurs  in  the  afternoon  or 
evening  it  is  best  to  let  the  child  go  until  morning  before  attempting  to 
feed  it.  Feeding  should  be  resumed  very  carefully.  In  nursing  infants 
it  is  best  to  allow  the  child  to  nurse  only  two  or  three  minutes  at  first, 
prolonging  the  nursing  time  according  to  the  indications.  For  arti- 
ficially fed  children  we  may  use  whey,  albumen-water,  or  a  weak  prep- 
aration of  one  of  the  cereal  foods,  allowing  only  b5-30  c.c.  (V  to  1  ounce) 
an  hour  at  first,  gradually  lengthening  the  interval  and  increasing  the 
quantity.  In  the  severer  cases  it  may  be  advisable  to  begin  with  tea- 
spoonful  feedings.  Milk  should  be  withheld  from  these  children  for 
several  days,  and  when  it  is  resumed  it  should  at  first  be  given  much 
more  dilute  than  the  child  had  been  taking  it  before  the  disturbance, 
barley-water  or  lime-water  being  used  as  the  diluent.  It  is  very  easy  to 
bring  on  a  relapse  in  these  ca,ses  by  too  rapid  progress  in  the  feeding. 
With  care  the  ordinarv  feeding  may  be  resumed  by  the  end  of  a  week. 
If  there  are  l(K)se  or  decayed  teeth  they  should  receive  attention. 

Drugs  are  usually  not  required  in  this  condition.  If  the  liowels  have 
not  moved  of  themselves  calomel  may  l>e  given  for  that  purpo.se,  0.0065- 
0.013  gm.  (y^Ty  grain  to  i  grain)  hourly  until  a  grain  has  been  taken. 
If  the  vomiting  persists  after  the  washing  the  following  powder  may  be 
given  with  advantage: 

I;l— Bismuth,  subnitralis, 

Cerium  osalatis, 

Sodium  bicarbonatis dd    2.0  gm.  (588). 

M.  et  div.  in  chart.  No.  xii. 

Sig. — One  powder  to  be  given  with  each  feeding. 

The  powder  may  l)e  given  dry  on  the  tongue  and  wa.shed  down  with 
a  little  water  or  milk,  or  it  may  be  given  in  a  small  portion  of  the  feeding. 


DISEASES  OF   THE   STOMACH  209 

Quiet  and  careful  dieting  are  the  essentials  in  the  management  of 
these  cases  and  medication  is  of  distinctly  secondary  importance. 
During  convalescence  the  bowels  may  be  constipated.  A  simple  enema 
of  500  c.c.  (1  pint)  of  water  is  the  best  means  of  moving  them,  but 
many  children  resist  the  administration  of  enemata  to  such  an  extent 
that  it  is  necessary  to  resort  to  medication  by  the  mouth.  Calomel 
may  be  given  again  in  the  manner  already  described,  or  7.50  c.c.  (about 
a  dessertspoonful)  of  the  milk  of  magnesia,  or  120-180  c.c.  (about  a 
glass)  of  the  effervescing  citrate  of  magnesia  may  be  employed. 


ACUTE  GASTRITIS, 

Etiology. — An  acute  catarrhal  inflammation  of  the  stomach  is  rela- 
tively rare  as  an  independent  lesion,  but  is  common  enough  as  an 
accompaniment  or  as  part  of  a  general  inflammation  of  the  intestinal 
tract.  It  is  frequently  associated  with  the  inflammation  of  the  intestine 
and  colon,  which  will  be  described  later.  It  is  present  in  many  of  the 
acute  infectious  diseases. 

The  primary  or  independent  form  may  be  produced  by  any  of  the 
causes  already  given  for  acute  gastric  indigestion.  Whether  we  shall 
get  in  a  given  case  an  attack  of  indigestion  or  an  active  inflammation 
of  the  stomach  depends  upon  the  resistance  of  the  stomach  in  that 
particular  case  and  the  virulence  of  the  exciting  cause.  The  most 
common  cause  in  infants  is  improper  feeding,  especially  in  the  case  of 
artificially  fed  children.  Breast  milk  may  be  so  indigestible  that  its 
use  produces  an  acute  catarrh  of  the  stomach,  but  such  cases  are  very 
rare.  In  the  artificially  fed,  acute  catarrh  of  the  stomach  is  common, 
especially  upon  sudden  changes  or  some  egregious  error  in  the  feeding. 
During  the  summer  it  is  not  uncommon  to  see  this  disorder  in  children 
from  a  single  feeding  of  milk  that  has  undergone  change  from  bacterial 
action. 

For  convenience  the  acute  gastritis  excited  by  the  administration  or 
accidental  taking  of  caustic  poisons,  such  as  carbolic  acid,  strong  acids 
or  alkalies,  etc.,  is  regularly  considered  under  this  head. 

Pathology. — The  gross  changes  are  not  marked.  The  stomach  is 
found  either  contracted  or  dilated.  Externally  it  is  normal.  On  opening, 
the  contents  are  found  to  consist  of  mucus  and  more  or  less  food.  The 
mucus  is  thick  and  ropy,  as  a  rule,  and  is  often  quite  firmly  adherent 
to  the  mucous  membrane.  Not  infrequently  the  mucus  is  mixed  with 
more  or  less  cofi^ee-ground  material,  which  analysis  proves  to  be  blood, 
doubtless  from  capillary  hemorrhages,  for  no  gross  lesions  of  the  blood- 
vessels can  be  found.  The  mucous  membrane  is  swollen  and  more  or 
less  congested,  especially  along  the  greater  curvature  and  near  the 
pylorus.  There  may  be  minute  hemorrhages  into  its  substance.  Micro- 
scopically there  may  be  a  loss  of  the  superficial  epithelium  and  some 
round-cell  infiltration  of  the  mucosa  and,  in  severe  cases,  of  the 
submucosa.  IMinute  extravasations  of  blood  may  also  be  found.  The 
14 


210  DISEASES  OF   THE   AUMENTMIY    TRACT 

changes  arc  very  likely  to  be  in  scattered  areas,  not  general.  The 
muscular  and  peritoneal  coats  are  normal. 

A  follicular  inflammation  of  the  stomach  is  a  rare  finding  in  these 
cases.  When  it  is  present  the  solitary  follicles  of  the  stomach,  which 
are  scattered  at  rather  wide  intervals  through  tiie  nnicous  membrane, 
are  swollen  and  in  the  centre  of  each  follicle  there  is  a  slight  superficial 
loss  of  epithelium  giving  the  aj)pearance  of  a  mimite  ulcer,  about  the 
si/.e  of  a  pinhead.  Rarely  does  the  ulceration  appear  more  considerable. 
These  changes  may  be  associated  with  those  of  a  catarilial  infhunmation. 
The  lesion  is  of  exactly  similar  type  to  that  seen  in  follicular  inflam- 
mation of  the  colon,  but  the  follicles  are  not  so  numerous  in  the  stomach. 

A  mcmhranous  inflammation  of  the  stomach  is  a  very  rare  finding  in 
the  postmortem-room.  It  is  usually  seen  in  association  with  some  one 
of  the  infectious  diseases.  It  is  more  often  not  diphtheritic.  I  have 
seen  one  case  in  which  the  diphtheria  bacilli  were  obtained  both  in 
smears  and  culture  from  the  membrane.  It  is  a  curious  fact  that  in 
these  cases  of  diphtheritic  iuHannnation  of  the  stomach  the  esophagus 
is  not  involved.  The  lesions  in  these  membranous  cases  are  those  of 
a  croupous  inflammation  of  any  mucous  membiaiic.  The  surface  of 
the  membrane  is  coated  with  an  exudate  of  fibrin,  leukocytes,  epithelium, 
and  bacteria.  The  underlying  mucous  membrane  is  rough,  granular, 
congested,  and  shows,  on  microscopic  examination,  a  more  extensive 
inhltration  with  leukocytes  extending  into  the  submucosa.  There  may 
also  be  small  extravasations  of  blood.  The  muscular  and  peritoneal 
coats  are  regularly  normal.  A  gangrenous  inflammation  of  the  stomach 
I  have  seen  only  once,  then  in  association  with  cancrum  oris.  The 
uuicous  membrane  of  the  stomach  was  greatly  swollen  and  thickened  l)y 
infiltration;  the  crests  of  the  rugie  were  coated  with  a  croupous  exudate, 
while  the  whole  mucous  membrane  was  soft,  greenish  black  in  color, 
and  emitted  the  characteristic  odor. 

In  cases  of  caustic  poisoning  the  mucous  membrane  presents  the 
appearance  of  an  acute  inflammation  with  more  or  less  scattered  ulcer- 
ation, the  extent  of  the  ulceration  depending  upon  the  amount  of  caustic 
which  has  reached  the  stomach.  This  is  usually  small.  The  ulceration 
mav,  in  rare  cases,  be  deep  enough  to  penetrate  the  walls  of  the  stomach. 

The  condition  of  c/astro malaria  is  occasionally  seen  in  autopsies  on 
children.  This  is  a  softening  of  the  wall  of  the  stomach  produced 
by  a  process  of  self-digestion.  A  considerabl(>  area  of  the  wall  is  reduced 
to  a  soft,  gelatinous  mass  which  readily  yields  to  any  tension  or  may 
have  already  permitted  the  escape  of  the  gastric  contents  into  the 
peritoneum.  The  area  involved  is  always  on  the  greater  curvature  and 
in  its  most  dependent  y)art.  There  are  none  of  the  usual  evidences  of 
inflammation  about  the  margins  of  the  softened  area,  or,  indeed,  in 
other  parts  of  the  stomach.  Considerable  importance  was  at  one  time 
attached  to  this  condition,  but  we  have  learned  that  it  has  no  relation 
to  disease  of  the  stomach  during  life. 

Symptomatology. — As  has  already  been  pointed  out  the  onset  of  acute 
catarrhal  inflammation  of  the  stomach  is  exactly  the  same  as  that  of 


DISEASES  OF   THE   STOMACH  211 

acute  gastric  indigestion.  The  two  affections  differ  only  in  their  course. 
In  acute  catarrh  the  vomiting  is  more  persistent.  The  vomitus  contains 
more  mucus,  after  a  time  it  may  become  greenish  from  admixture  of 
bile,  and  in  some  instances  shows  a  little  blood.  The  bleeding  is  never 
sufficient  to  be  of  importance  in  itself.  The  vomiting  continues  for 
several  days  or  even  a  week  or  more.  The  tongue  is  very  heavily  coated 
and  may  be  swollen.  Thirst  is  severe  and  the  older  children  complain 
of  the  bad  taste  of  the  mouth.  The  abdomen  is  distended  and  there 
is  tenderness  to  pressure  over  the  epigastrium.  The  bowels  may  be 
constipated  at  first,  but  there  is  often  a  diarrhea  later.  The  urine  is 
scanty,  high-colored,  of  high  specific  gravity,  and  contains  urates  or 
uric  acid.  The  constitutional  symptoms  at  the  onset  may  be  severe  or 
slight.  The  temperature,  if  high  at  the  beginning,  soon  falls  and  there- 
after rarely  exceeds  101°  F.  The  pulse  in  the  severer  cases  may  be  rapid 
and  small.  After  the  first  few  days  the  repeated  vomiting,  the  restless- 
ness, and  severe  thirst  are  the  prominent  symptoms.  The  affection 
runs  its  course  in  a  week,  as  a  rule,  but  unless  care  is  taken  the  disease 
may  be  protracted  much  beyond  this.  Herpes  labialis  is  not  infrequent 
in  older  children. 

The  follicular  inflammation  of  the  stomach  is,  as  already  stated,  very 
rare  indeed  and  presents  no  peculiarity  in  its  course  beyond  the  fact 
that  in  the  nature  of  things  recovery  v.'ill  be  much  slower.  It  is  no  more 
likely  to  be  attended  with  hemorrhage  than  the  simpler  form  of  inflam- 
mation. 

The  membranous  gastritis  is  a  pathological  curiosity  which  most 
often  gives  no  symptoms  of  its  own  and  is  recognized  only  at  autopsy. 
It  is  conceivable  that  shreds  of  membrane  might  be  vomited,  but,  so 
far  as  known,  they  have  never  been  observed. 

Of  the  symptoms  of  gangrenous  gastritis  nothing  is  known.  In  the 
single  case  alhided  to  there  were  no  symptoms  pointing  to  an  unusual 
affection  of  the  stomach. 

Diagnosis. — This  is  usually  determined  by  the  course  of  the  affection. 
The  distinctive  points  from  an  acute  indigestion  have  already  been 
pointed  out.  As  in  that  affection,  one  may  fear  the  onset  of  one  of  the 
acute  infectious  diseases;  especially  are  typhoid  fever  and  meningitis 
to  be  remembered,  but  a  few  days'  observation  usually  renders  the 
nature  of  the  affection  clear.  If  the  cause  of  the  disturbance  can  be 
discovered,  especially  if  this  lie  in  the  matter  of  feeding,  the  diagnosis 
can  more  readily  be  ventured. 

Prognosis. — The  prognosis  is  generally  good.  In  weak  infants, 
however,  an  attack  of  acute  gastritis  may  be  cpiickly  fatal,  or  the 
infant  may  be  left  so  exhausted  that  it  gradually  fails.  The  majority 
of  the  cases  recover  promptly  under  good  care.  When  this  is  lacking 
the  affection  may  become  chronic.  The  prognosis  in  the  toxic  cases 
will  depend  upon  the  quantity  of  the  poison  taken  and  the  promptness 
of  treatment.  Even  when  they  recover  the  children  are  likely  to  be  left 
with  cicatricial  stenosis  of  the  esophagus  or  deformities  of  the  stomach 
which  will  in  the  end  prove  fatal. 


212  DISEASES  OF   THE   ALIMENTARY    TRACT 

Treatment. — During  the  early  stages  this  is  to  be  conducted  exactly 
on  the  lini>s  laid  down  under  acute  gastric  indigestion.  If  the  temper- 
ature is  high  a  sponge  bath  (water  at  S5°  to  \)0°  F.)  for  ten  minutes 
will  lower  the  fever  and  help  to  (piiet  the  patient.  If  the  vomiting 
persists,  lavage  of  the  stomach  is  the  best  of  remedies.  It  may  be 
repeated  once  or  twice  daily  if  necessary.  For  the  relief  of  the  thirst 
snudl  bits  of  ice  may  be  given  to  be  held  in  the  mouth  or  in  the  youngest 
patients  a  teaspoonful  of  cool  water.  In  the  severe  cases  small  amounts 
of  water,  ()().()-120.0  c.c.  (2-4  oz.),  may  be  given  by  the  rectum  and 
repeated  fre(|uently,  if  the  administration  does  not  greatly  excite  the 
patient.*  Early  attempts  to  feed  the  patient  are  more  likely  to  do  harm 
than  good.  Feeding  is  to  be  begun  as  indicated  in  the  preceding  chapter. 
The  use  of  milk  should  be  postponed  for  several  days,  and  when  it  is 
resumed  it  should  invariably  be  given  as  whey  or  much  more  diluted 
than  the  child  had  been  previously  having  it.  Barley-water  or  lime- 
water  should  be  used  as  the  diluent  to  prevent  the  formation  of  thick 
curds.  Once  milk  has  been  satisfactorily  begun  it  should  be  increased 
very  gradually  day  by  day  until  the  patient  is  getting  the  normal  amount. 
Freedom  from  vomiting,  the  return  of  the  appetite,  and  the  conrlition 
of  the  bowels  should  be  our  guides  in  making  increases  in  the  feeding. 
Any  return  of  the  symptoms  is  a  signal  for  further  dilution  of  the  milk. 

In  cases  of  corrosive  poisoning  the  use  of  the  tube  must  usually  be 
avoided,  both  on  account  of  the  spasm  of  the  pharynx  and  esophagus 
and  of  the  danger  of  furthering  a  perforation.  If  the  patient  has  not 
already  vomited,  water  should  be  given  in  large  quantities,  together 
with  the  proper  antidote,  which  will  probably  have  the  effect  of  causing 
vomiting,  and  at  the  same  time  neutralize  the  poison.  If  the  antidote 
is  not  at  hand,  there  should  be  no  delay  in  giving  the  water.  Later,  milk, 
oils,  or  albumen-water  may  be  given  freely.  After  the  first  few  hours 
the  treatment  must  be  on  the  lines  of  any  acute  gastritis,  except  that 
washing  the  stoinach  is  not  advisable,  and  that  morphine  is  required 
for  relief  of  suffering.  It  should  be  given  hypodermically.  The  combi- 
nation of  bismuth,  cerium,  and  soda,  given  in  the  section  relating  to 
Gastric  Indigestion,  may  be  employed  with  advantage,  or  bismuth  alone, 
0.324-0. Of)!)  gm.  (5  to  10  grains)  every  two  hours.  The  severer  cases 
should  be  treated  with  every  care.  The  sick-room  should  be  light  and 
well  aired.  The  patient  should  have  at  least  one  tepid  or  warm  bath 
daily,  depending  upon  his  general  condition ;  the  bowels  should  be  moved 
once  daily;  complete  rest  and  quiet  should  be  enjoined.  Unless  care  is 
taken  in  all  details  one  relapse  mav  follow  another  mitil  the  acute  con- 
dition has  become  chronic  and  ultimate  recovery  considerably  delayed. 


CHRONIC  GASTRITIS. 

Chronic  Gastritis,  Gastric  Catarrh,  or  Chronic  Vomiting  is  one  of  the 
most  frequent  of  the  disorders  of  digestion  met  with  in  infancy.  It  is  a 
question  whether  in  some  cases  there  is  an  actual  inflammation  of  the 


DISEASES  OF   THE   STOMACH  213 

stomach  or  whether  the  disturbance  is  not  purely  functional,  but  the 
distinction  is  not  of  practical  importance.  Chronic  gastritis  is,  in  most 
cases,  associated  with  a  similar  disorder  of  the  intestine  and  colon.  As 
the  recent  researches  of  Pawlow  have  emphasized  for  us,  the  process  of 
digestion  cannot  be  properly  separated  into  several  independent  acts; 
it  is  a  continuous  process,  the  proper  performance  of  each  step  being 
essential  to  that  which  is  next  in  order.  Thus  the  best  stimulus  to 
intestinal  digestion  is  the  outflow  of  normal  chyme  from  the  stomach 
into  the  intestine.  Imperfection  in  this  lessens  the  normal  stimulus  to 
the  intestine,  and  in  turn  impairs  the  intestinal  digestion.  So  a  chronic 
gastritis  cannot  long  continue  without  disturbing  the  functions  of  the 
intestine,  which  may  in  turn  give  symptoms,  but  practically  the  stomach 
continues  to  be  the  source  of  most  trouble  and  we  can  best  consider  the 
cases  under  this  heading. 

Etiology. — This  disorder  is  seen  in  infants  who  are  improperly  fed 
and  usually  badly  cared  for.  Infants  on  the  breast  do  sometimes 
develop  chronic  gastritis,  but  very  rarely.  Among  the  poor  the  matter 
of  the  care  of  the  children  seems  to  be  of  almost  as  much  importance 
as  the  food  in  determining  their  welfare.  Lack  of  sunlight,  bad  air, 
poor  food,  irregidarity  in  feeding,  and  exposure  to  cold  and  wet  may 
all  play  a  part  in  inducing  such  disorders  as  gastritis.  The  early 
giving  of  tea  and  coffee  or  liquors  may  be  met  with  in  some  cases.  The 
presence  of  some  constitutional  disorder  which  lowers  the  tone  of  all 
the  tissues,  such  as  rickets,  syphilis,  tuberculosis,  or  anemia,  may  be  an 
indirect  factor.  Cardiac  disease  or  chronic  affection  of  the  lungs  or 
liver  which  will  produce  a  chronic  venous  congestion  of  the  stomach 
may  induce  a  chronic  catarrh.  In  convalescence  from  any  of  the  acute 
infections,  the  functions  of  the  stomach  are  impaired  and  a  chronic 
gastritis  may  be  easily  developed.  It  is  said  that  repeated  attacks  of 
acute  gastritis  may  beget  a  chronic  condition,  but  this  is  doubtful  unless 
the  cause  of  the  acute  attacks  is  still  active  in  the  intervals. 

In  older  children  chronic  gastritis  is  usually  the  result  of  the  persistent 
use  of  indigestible  foods  (pastry,  pickles,  pies,  candies,  etc.),  or  bad 
habits  of  eating  (eating  too  rapidly,  eating  at  irregular  hours,  etc.), 
or  exercising  violently  immediately  after  eating,  etc. 

Pathology, — The  gross  changes  to  be  observed  in  the  stomach  in  these 
cases  are  hardly  in  proportion  to  the  gravity  of  the  disease.  The  stomach 
is  nearly  always  somewhat  enlarged,  the  mucous  membrane  shows  few 
ruga^,  but  appears  smooth,  may  be  injected  in  places,  and  is  regularly 
covered  with  more  or  less  tenacious  mucus. 

The  advanced  stages  of  chronic  gastritis  with  much  connective  tissue 
in  the  wall  of  the  stomach  I  have  never  seen  in  infants  or  children. 
The  solitary  follicles  of  the  stomach  may  be  eidarged.  Microscopically, 
the  stomach  walls  show  more  or  less  infiltration  with  round  cells  about 
the  tubules,  with  secondary  degenerative  changes  in  the  epithelium  of  the 
tubes  (Fig.  39).    Similar  changes  may  be  found  in  the  intestine  or  colon. 

Symptomatology. — Owing  to  these  morbid  changes  in  the  stomach 
wall  the  secretion  of  hydrochloric  acid  and  pepsin  or  pepsinogen   is 


214  DISEASES  OF   THE  A  LIMES  TART    TRACT 

definitely  impaired;  the  process  of  digestion  is  therefore  delayed;  the 
food  remains  in  the  stomach  much  longer  than  it  normally  should — even 
six  or  eight  hours — ferments  and  tlecompost's  with  tlu'  production  of  giis. 
The  stomach,  therefore,  gets  none  of  the  normal  rest  between  meals;  is 
constantly  dilated  more  and  more  by  the  accumulating  food,  nmcus,  and 
gtts,  so  that  the  tendency  is  constantly  toward  a  worse  condition.  The 
early  and  predominant  sym])tom  of  chronic  gastritis  is  vonn'ting.  This 
at  first  may  occur  only  rarely  and  be  small  in  amount.  It  steadily 
increases  in  frequency  and  amount  until  it  becomes  more  or  less  constant, 
the  child  vomiting  after  every  feeding,  upon  the  slightest  movement  or 
apj)arently  without  cause.  With  the  onset  of  the  vomiting  the  cliild 
ceases  to  gain  normally,  then  begins  to  lose  weight  and  loses  steadilv, 

Fig.  39 


Follicular  ulceration  of  the  stomach,  a  rare  le«iou  accompanying  chronic  gastritis.  Stomach  of  a 
child,  eight  months  old,  turned  inside  out  and  stutTed  with  horsehair.  Cardiac  end  above,  showing 
rugae. 

the  subcutaneous  fat  disappearing  from  tlie  bodv,  the  muscles  becoming 
flabby,  the  skin  dry,  loose,  and  of  a  sallow  tint;  the  face  thin  and  pinched; 
the  eyes  sunken,  but  clear  and  bright;  the  fontanel  depres-sed.  In  short, 
the  child  presents  the  ])icture  of  marasmus  so  familiar  to  all.  The 
tongue  is  usually  coated ;  the  breath  may  be  foul ;  the  appetite  is  capricious, 
usually  impaired,  but  it  sometimes  remains  surprisingly  good;  the 
bowels  are  constipated,  but  may  be  loose  if  the  functions  of  the  intestines 
are  also  impaired.  The  abdomen  is  usually  di.stended  with  gas,  and  is 
therefore  markedly  tympanitic,  especially  in  the  epigastrium.  As  the 
svmptoms  increase  the  child  becomes  verv  restless  and  fretful,  crving 
more  or  less  of  the  time,  and  getting  very  little  quiet  sleep.  Gradually 
the  streuirth  fails  until  death  ensues. 


DISEASES  OF   THE   STOMACH  215 

In  advanced  cases  the  children  become  greatly  emaciated  and  lie  as 
though  lifeless ;  the  feet  and  hands  are  cold,  the  pulse  almost  imperceptible, 
the  respirations  feeble  and  shallow;  they  cry  only  when  disturbed;  they 
take  very  little  or  no  nourishment,  and  yet  vomit  from  time  to  time  the 
acid  mucus.  In  this  state  they  may  linger  for  weeks  before  life  ceases 
altogether,  and  from  even  this  exhausted  condition  proper  care  may 
rescue  them. 

In  older  children  the  vomiting  is  not  so  pronounced,  but  is  still  the 
marked  feature  of  these  cases;  the  tongue  is  coated;  the  abdomen 
prominent  and  tympanitic;  the  bowels  constipated.  The  children  are 
very  peevish  and  fretful;  they  may  increase  in  stature,  but  the  muscles 
are  poorly  developed  and  their  vitality  is  very  much  impaired. 

The  vomitus  in  these  cases  at  first  consists  only  of  food;  later,  as  the 
vomiting  increases  in  frequency,  it  comes  to  consist  more  and  more  of 
sour-smelling,  acid  mucus,  with  but  little  food.  The  analysis  of  the 
gastric  contents  or  vomitus  may  or  may  not  show  the  presence  of  hydro- 
chloric acid.  It  will  regularly  show  the  presence  of  acetic,  butyric, 
lactic,  and  other  organic  acids,  resulting  from  the  abnormal  fermentation 
going  on  in  the  stomach. 

Diagnosis. — There  is  little  difficulty  in  these  cases.  The  history  of 
the  case,  the  character  of  the  vomiting,  and  the  results  of  physical 
examination  are  distinctive.  A  chronic  meningitis  might  produce 
similar  vomiting,  but  would  be  readily  recognized  by  other  signs.  The 
important  point  in  this  relation  is  to  search  these  cases  of  chronic  vomit- 
ing for  evidences  of  pyloric  obstruction,  for  it  has  been  clearly  estab- 
lished that  a  certain  number  of  them  suffer  from  an  hypertrophic  obstruc- 
tion of  the  pylorus,  which  is  amenable  to  treatment  by  operative  measures. 
(See  Congenital  Hypertrophy  of  the  Pylorus.) 

Prognosis. — Chronic  gastric  catarrh  is  always  a  serious  affection  in 
infancy.  Undoubtedly  many  infants  through  this  affection  become 
marantic  and  ultimately  die.  Many  more  are  so  weakened  by  it  that 
they  fall  ready  victims  to  the  diarrheal  diseases  of  the  summer  or  the 
bronchitis  or  bronchopneumonia  of  winter.  Under  proper  care,  however, 
the  prospect  of  recovery  is  good  and  the  infant  may  grow  up  into  a 
vigorous  adult.  In  later  childhood  the  affection  is  much  less  serious  as 
regards  life,  but  almost  always  entails  some  failure  of  development, 
either  in  stature  or  in  the  tone  of  the  muscular  and  nervous  system. 
Good  care  and  perseverance  will,  however,  in  many  cases  restore  the 
child  to  perfect  health. 

Treatment. — The  treatment  of  these  cases  must  be  both  general  and 
special.  These  children  should  have  abundance  of  sunlight  and  air,  and 
yet  they  should  not  be  allowed  to  become  chilled  by  cold.  In  summer  they 
should  live  out-of-doors.  During  the  cold  months  they  should  be  out 
several  hours  daily,  if  this  is  compatible  with  keeping  the  circulation  in 
a  proper  state.  They  should  be  dressed  warmly  and  wear  a  flannel 
band  and  woollen  stockings.  The  feet  should  be  especially  watched  to 
make  sure  that  they  are  always  warm.  Great  care  should  be  exercised 
to  prevent  infants  being  made  wet  by  the  vomitus ;  a  towel  should  be  kept 


216  DISEASES  OF   THE  ALIMENTARY   TRACT 

folded  under  the  oliin,  if  necessary,  and  changed  as  often  as  it  becomes 
wet.  Napkins  when  wet  or  soiled  should  he  changed  pronijitly.  Each 
of  these  details  will  add  to  the  comfort  and  welfare  of  the  child.  In 
the  marantic  cases  a  thorough  ruhhiug  and  massaging  once  daily  with 
olive  oil  or  cocoa-butter  aids  nutrition  and  helps  the  circulation.  The 
custom  of  using  cod-liver  oil  for  this  purpose,  because  it  is  supposed  to 
be  absorbed  and  act  as  a  food,  has  no  sound  basis  in  })hysiology  or 
experience,  and  is  extremely  objectionable  because  of  the  odor. 

The  question  of  the  regulation  of  the  diet  in  these  cases  is  a  most 
difficult  one,  especially  in  the  cases  of  breast-fed  infants,  and  yet  of 
the  utmost  importance.  We  occasionally  see  breast-fed  infants  who 
are  vomiting  persistently  and  failing  in  consequence,  yet  the  analysis 
of  the  milk  shows  no  error  in  its  composition  to  satisfactorily  explain 
the  disturbance.  The  only  thing  possible  in  such  case  is  to  resort  to 
a  modification  of  cows'  milk.  If,  on  the  other  hand,  definite  irregular- 
ities can  be  found  in  the  breast  milk,  and  these  can  be  corrected  by 
changing  the  mother's  mode  of  life  or  feeding,  then  we  may  hope  for 
improvement  in  the  infant's  symptoms.  Thus,  if  the  mother's  milk  is 
deficient  in  fat  and  over-rich  in  proteids,  we  can  usually,  by  feeding 
her  more  fat— i.e.,  giving  cream,  butter,  and  meats  freely,  and  enjoin- 
ing exercise — correct  this  irregularity  and  so  help  the  child;  or  we  may 
resort  to  a  maneuvre  which  I  have  found  to  serve  the  purpose  in 
several  instances,  namely,  have  the  mother  remove  one-half  to  one 
ounce  of  milk  from  the  breast  before  allowing  the  infant  to  nurse.  The 
first  part  of  the  milk,  it  is  well  known,  contains  less  fat  and  more  proteid; 
the  latter  part  of  the  milk  is  richer  in  fat  and  poorer  in  proteid,  which  is 
just  the  part  which  is  desired  in  such  case.  This  plan  also  has  the  advan- 
tage of  reducing  the  quantity  that  the  infant  can  get  at  any  one  nursing. 

If,  however,  the  milk  is  over-rich  in  fat,  the  withdrawal  of  cream,  milk, 
butter,  and  perhaps  meats,  from  the  mother's  diet,  will  reduce  the  fat  to 
nearer  normal.  But  at  the  best  we  find  that  the  amount  of  control  which 
we  can  exercise  over  the  breast  milk  is  slight,  and  results  in  most  cases  are 
unsatisfactory.  Even  in  the  matter  of  control  of  nursing  time,  which 
one  would  assume  would  fairly  well  determine  the  amount  of  milk  a 
child  would  get  at  a  nursing,  careful  observation  has  shown  me  that 
the  amount  of  milk  taken  in  a  five  minutes'  nursing  may  vary  greatly 
at  different  hours  of  the  day.  In  a  nursing  baby  we  should,  therefore, 
analyze  the  milk  or  have  it  analyzed  and  endeavor  to  correct  any  irreg- 
ularities discoverable.  Nursing  should  not  be  permitted  more  fre(|uently 
than  once  in  three  hours,  at  least  one  nursing  being  omitted  during  the 
night,  and  the  nursing  time  should  be  reduced  one-half  at  first.  If 
these  measures  bring  a  definite  improvement  they  may  be  persisted  in, 
the  nursing  time  being  gradually  lengthened  again  until  the  infant  is 
getting  all  he  desires.  In  most  cases,  however,  we  shall  be  tlriven  to 
secure  a  wet-nurse  or  resort  to  artificial  feeding. 

In  artificial  feeding  we  have  the  great  arlvantage  of  being  able  to 
control  exactly  the  composition  of  the  food,  the  hours  of  feeding,  and 
the  amount  given  at  any  one  time. 


DISEASES  OF   THE   STOMACH  217 

In  a  case  of  chronic  gastritis  in  an  artificially  fed  infant,  a  change  to 
the  breast  may  be  of  the  utmost  vahie,  and  wherever  it  is  feasible  a 
wet-nurse  should  be  tried.  Sometimes  trial  must  be  made  of  several 
before  a  satisfactory  one  is  obtained,  the  difficulty  lying  either  in  the 
composition  of  the  woman's  milk  or  in  the  digestive  powers  of  the  infant. 

If  artificial  feeding  must  be  resorted  to  or  relied  upon  then  the  pro- 
portions of  the  food  must  be  made  very  low  and  the  quantity  of  the 
feeding  reduced  greatly  in  amount.  A  guaranteed  milk,  or  a  milk  the 
freshness  and  cleanliness  of  which  are  assured,  should  be  secured  and, 
to  begin  with,  diluted  with  9  parts  of  a  5  per  cent,  milk-sugar  solution 
(made  by  dissolving  1  ounce  of  milk-sugar  in  20  ounces  of  water).  This 
would  give  a  mixture  containing  0.4  per  cent,  fat,  5.5  per  cent,  sugar, 
and  0.4  per  cent,  proteids.  An  ounce  of  such  food  may  be  given  once  in 
three  hours  at  first,  and  the  quantity  gradually  increased,  if  it  agrees  w4th 
the  infant,  until  nearly  the  normal  amount  is  taken.  Then  the  strength 
of  the  milk  may  be  gradually  increased  by  diluting  a  less  number  of  times. 
The  upward  progress  must  be  made  slowly.  Any  attempt  to  rapidly 
increase  the  strength  of  the  milk  is  sure  to  be  followed  by  a  return  of 
the  vomiting,  and  it  is  quite  surprising  on  how  small  a  quantity  of  a  weak 
food  an  infant  will  get  along  well,  if  only  the  food  is  properly  digested. 
If  raw  milk  cannot  be  taken  the  milk  may  be  peptonized  and  then 
diluted.  If  this  is  well  borne  the  dilution  is  gradually  lessened,  and 
when  the  infant  has  taken  this  for  several  days  the  duration  of  the 
peptonizing  process  may  gradually  be  shortened  until  the  infant  is  able 
to  take  raw  milk.  It  seems  to  be  an  advantage  to  use  whatever  digestive 
power  the  infant  has,  but  I  have  known  of  instances  in  which  the  pepton- 
ization has  been  required  throughout  the  first  year. 

In  severe  cases  it  may  be  that  milk  in  any  form  cannot  be  borne  and 
for  a  time  we  are  forced  to  resort  to  other  foods.  Fresh  beef-juice  may 
then  be  used,  one  to  four  teaspoonfuls  diluted  with  an  equal  part  of 
water,  chicken-broth  in  quantities  of  one  to  four  tablespoonfuls,  or  the 
preparation  known  as  peptonoids  or  panopepton,  one  or  two  teaspoonfuls 
diluted  four  or  more  times  with  water,  for  a  feeding.  It  is  to  be  remem- 
bered that  the  latter  preparations  contain  about  20  per  cent,  of  alcohol, 
and  are  therefore  stimulants  as  well  as  foods.  Valentine's  beef-juice  is 
also  at  times  a  serviceable  preparation.  After  a  day  or  two  on  such 
substitutes  the  peptonized  milk  should  be  tried  again.  Whey  is  also 
an  excellent  and  valuable  preparation  for  trial  in  these  cases;  or  in 
children  over  six  months  of  age  barley-water  or  rice-water  may  be  used. 
These  latter  preparations  have  the  advantage  that,  if  the  infant  will 
retain  them,  after  a  day  or  two  milk  may  be  added  to  the  whey  or 
barley-water,  beginning  with  a  single  teaspoonful  to  each  feeding,  and 
increasing  the  quantity  day  by  day  according  to  the  indications. 

All  of  these  foods  are  best  given  cold,  and  in  bad  cases  it  may  be 
found  wise  to  put  aside  the  bottle  and  give  all  food  for  a  time  from  a 
teaspoon.  When  an  infant  refuses  food  altogether  its  life  may  be  saved 
by  feeding  it  regularly  through  a  stomach  tube  for  a  day  or  two.  In 
all  cases  the  greatest  care  should  be  taken  of  the  infant's  mouth,  the 


21$  DISEASES  OF   THE  ALBfEXTARY   TRACT 

luirse  boinoc  instructed  to  carefully  cleanse  the  mouth  with  a  2  per  cent, 
solution  of  boric  aci<l  after  each  feediiif;.  Unless  this  is  done  a  stomatitis 
or  thrush  is  cjuite  liki>ly  to  develo})  and  further  complicate  the  case, 
if  it  (hnvs  not  ])rove  fatal. 

From  time  to  time  one  sees  cases  of  chronic  gastritis,  in  which,  after 
lono;  trial,  a  proprietary  food  has  been  found  which  the  infant  takes  and 
retains,  l)ut  upon  which  it  will  not  thrive.  In  such  cases  it  is  a  ijood 
plan  not  to  try  radical  changes  of  the  food,  but  to  add  milk  or  cream 
ij-raduallv  to  it,  exactlv  as  we  would  add  it  to  whey  or  i)arlcy-water. 
If  the  infant  can  be  kept  comfortable  it  is  usually  an  easy  matter  to  get 
it  to  gain  by  such  means.  The  key  to  success  is  the  very  gradual 
increase  in  the  strength  of  the  food,  after  comfort  has  once  been  secured. 

In  cases  of  great  exhaustion  it  is  of  the  utmost  importance  to  maintain 
the  bodv  heat  and  improve  the  circulation.  Hot-water  l)(^ttles  should 
be  kept  constantly  at  the  feet.  Dry  friction  of  the  extremities  is  also 
advisable  from  time  to  time.  If  collapse  occur  a  hot  mustard  bath 
should  be  given,  the  whole  body  being  immersed  until  reaction  is  excited 
and  the  skin  becomes  flushed. 

For  the  direct  relief  of  tlie  vomiting,  stomach  washing  should  be 
employed.  It  has  the  advantage  of  not  only  removing  the  mucus  and 
decomposing  food,  l)ut  of  also  stimulating  the  normal  secretion  of  the 
mucous  meml)rane. 

A  solution  of  sodium  bicarbouate,  4.0  gm.-.")00  c.c.  fa  drachm  to  the 
pint),  should  i)e  used  at  a  temperature  of  100°  F.  The  washing  should 
be  repeated  daily  at  first,  later  every  second  or  third  day. 

Medicinal  treatment  is  of  little  service.  The  great  majority  of  gastric 
sedatives  have  no  effect  whatever.  Starr,  however,  reconuntMids  the  use 
of  Fowler's  solution  in  the  following  form  for  a  child  of  three  months: 

^—Liquor  potassii  arsenitis 1  00  c.c.  (Ill  xvj>. 

Sodii  bicarbonatis l..'>6  gm.  (gr.  xxiv). 

Aquffi  uienthii;  piperiUe  .        .    q.  s.  ad    100.00  c.c.  (Siij). 

Sig. — i  c.c.  (one  tea.<iKKinful)  in  a  little  water,  t.  i.  d. 

Tincture  of  mix  vomica  may  be  given  in  the  same  dose,  to  improve 
the  appetite  and  stimulate  the  mu.scular  action  of  the  stomach.  A  small 
o-raduate  .should  be  used  to  measure  each  dose.  The  hou.sehold  teaspoon 
varies  .so  greatlv  in  its  content  that  much  more  than  the  intended 
dose  niav  be  given.  By  actual  measurement  nine  teaspoonfuls  have  been 
found,  in  some  cases,  eipial  to  (iO  c.c.  (2  ounces). 

If  constipation  develops  in  the  course  of  treatment  it  is  best  to  move 
the  bowels  i\v  the  use  of  a  gluten  or  glycerin  suppository  or  a  simple 
enema  of  .soapsuds. 

In  older  childreu  the  same  general  ])lan  of  treatment  mu.st  be  followed, 
and  greater  difficulties  may  be  encountered  by  rea.son  of  the  unwilling- 
ness of  the  children  to  submit  them.selves  to  the  necessary  regime.  The 
general  hvgiene  of  the  child  mu.st  be  attended  to.  As  much  time  as 
po.ssii^le  .should  he  spent  in  the  open  air.  In  tho.se  of  .school  age  it  may 
be  uecessarv  to  forbid  attendance.  Moderate  exercise  .should  be  secured, 
with  care  tliat  exerci.se  is  not  carried  to  the  point  of  overfatigue.     The 


DISEASES  OF   THE   STOMACH  219 

sleeping-room  should  be  well  aired,  and  the  child  should  be  in  bed 
by  eight  o'clock.  The  morning  bath  should  be  as  stimulating  as  possible. 
With  sensitive,  weakly  children  the  use  of  cold  water  is  always  objected 
to.  The  mother  is  therefore  instructed  to  give  the  child  a  cleansing  bath 
at  whatever  temperature  is  comfortable  to  it,  determining  the  temper- 
ature by  a  thermometer;  then,  while  the  child  stands  in  the  tub,  to 
sponge  it  rapidly  with  water  a  degree  or  two  colder,  and  follow  this 
with  a  vigorous  rub.  Day  by  day  the  temperature  of  the  water  used 
for  sponging  is  gradually  lowered,  until  the  child  is  getting  a  bath  that 
brings  a  vigorous  reaction.  With  a  little  firmness  this  can  always  be 
accomplished. 

Three  meals  a  day  are  sufficient,  the  heaviest  meal  being  given  at 
noon.  For  the  breakfast  and  supper,  milk  should  be  the  mainstay,  given 
at  first  diluted  with  plain  water,  barley-water,  or  Vichy  water,  at  least 
one-half.  Drv  toast  or  zwieback  mav  be  o;iven  with  it,  or  graham 
biscuit,  not  the  flat  crackers  which  are  often  used.  Soft-boiled  eggs  or 
fish  may  l)e  allowed  later.  The  dinner  should  consist  of  clear  soups  with- 
out condiments,  meats,  and  later  the  simpler  vagetables,  spinach,  celery, 
cauliflower,  peas,  etc.    iA.ll  pastry  and  sweets  should  be  forbidden. 

Thorough  mastication  of  the  food  required,  and  no  other  fluids  than 
milk  or  water  allowed.  Dilute  hydrochloric  acid,  0.30-0.60  c.c.  (5  to  10 
drops),  and  tincture  of  nux  vomica,  0.06-0. IS  c.c.  (1  to  3  drops),  may  be 
given  after  each  meal  with  advantage,  but  here,  as  in  the  case  of  infants, 
reliance  must  be  put  upon  diet  and  life  rather  than  in  medicines. 

Stomach  washing  cannot  be  employed  in  these  cases,  but  instead  large 
draughts  of  warm  water  mav  be  given  an  hour  before  meals.  It  seems  to 
be  an  advantage  to  have  the  water  sipped,  rather  than  swallowed  rapidly. 

For  constipation  in  these  cases  small  doses  of  cascara  sagrada, 
0.065-0.130  gm.  (1  to  2  grains)  of  the  extract,  or  2.0  c.c.  (5ss)  of  the 
aromatic  fluid  extract,  may  be  given  at  night,  or  the  regular  use  of  the 
familiar  mist,  rhei  et  sod»  comp.,  4-8  c.c.  (oj-ij)  t.  i.  d.,  p.  c. 

A  flannel  binder  should  always  be  worn;  the  feet  should  be  kept 
warm,  and  all  exposure  to  wet  and  cold  guarded  against. 


DILATATION  OF  THE  STOMACH. 

Etiology. — Dilatation  of  the  stomach  in  infancy  and  childhood  arises 
from  causes  similar  to  those  operative  in  adult  life.     In  general  they  are: 

1.  Obstruction  to  the  passage  of  food  from  the  stomach,  usually 
occurring  at  the  pylorus,  and  resulting  in  distention  of  the  organ  from 
the  retention  and  decomposition  of  the  food.  The  most  frequent  cause 
of  such  obstruction  is  an  hypertrophy  of  the  pylorus,  which  will  be 
treated  separately.  Other  causes  are  mentioned  in  literature,  such  as 
congenital  strictures  or  obliteration  of  the  duodenum  or  pylorus;  stric- 
tures of  the  pylorus  from  the  scars  or  uicers ;  vohiilus  high  in  the  small 
intestine,  etc.;  but  they  are  all  extremely  rare  and  practically  bey^ond 
our  powers  of  diagnosis. 


220  DISEASES  OF   THE  ALIMENTARY    TRACT 

2.  Weakening  of  the  musenlar  wall  of  the  stomach.  This  occurs 
from  a  number  of  constitutional  causes,  especially  rickets,  syphilis, 
tuberculosis,  or  severe  anemia.  It  develops  also  to  a  greater  or  less 
extent  in  most  cases  of  chronic  gastritis.  It  is  this  form  which  presents 
itself  practically  and  deserves  consideration. 

Pathology. — The  apparent  size  of  the  stomach,  as  seen  in  autopsies 
on  children,  varies  greatly,  and  depends  to  a  considerable  extent  on 
whether  the  organ  is  contracted  or  relaxed  at  death.  The  actual  size 
and  capacity,  of  course,  increase  rapidly  from  birth  onward.  The 
normal  capacity  at  birth  averages  from  30-45  c.c.  (1  to  11  ounces),  at 
three  months  from  120-lSO  c.c.  (4  to  G  ounces),  at  six  months  about 
180  c.c.  (G  ounces),  and  at  twelve  months  from  240-300  c.c.  (S  to  10 
ounces).  The  capacity  of  a  dilated  stomach  may  greatly  exceed  these 
figures.  Holt  reports  a  child  three  months  old  with  a  stomach  capacity 
of  nine  ounces;  another  four  and  one-half  months  old  with  a  capacity 
of  ten  ounces;  and  an  extreme  case  of  a  two-weeks-old  baby  with  a 
stomach  holding  seventeen  ounces.  Apart  from  the  dilatation  these 
stomachs  usually  show  the  evidences  of  a  chronic  gastritis. 

Symptomatology. — The  symptoms  arc  those  of  aclironic  gastric  catarrh. 
The  infants  present  the  usual  picture  of  chronic  vomiting,  with  resulting 
failure  of  nutrition.  The  vomiting  is  rarely  of  such  large  quantities  as 
are  seen  in  adult  life.  The  vomitus  may  or  may  not  contain  hydro- 
chloric acid,  but  does  show  lactic  acid  and  other  products  of  abnormal 
fermentation,  and  in  some  cases  yeast  and  sarcina\  The  condition  is 
recognizable  by  the  results  of  physical  examination.  The  abdomen  is 
distended,  particularly  in  the  epigastric  region;  this  part  of  the  abdomen 
being  sometimes  quite  fidl,  while  the  remainder  is  flat.  In  an  emaciated 
child  the  outlines  of  the  stomach  may  be  seen  through  the  alxlominal 
wall.  If  the  greater  curvature  is  at  the  level  of  the  imibilicus,  or  below, 
we  may  be  quite  sure  that  the  stomach  is  dilated.  (lastroptosis  without 
dilatation  of  the  stomach  is  practically  unknown  in  childhood.  Per- 
cussion over  the  empty  stomach  gives  a  loud,  resonant  tympanitic  note, 
which  may  enable  us  to  outline  the  organ  without  artificial  distention. 
It  Is  frecjuently  possible,  by  passing  a  stomach  tube,  filling  the  stomach 
with  water,  and  then  emptying  it,  to  demonstrate  an  abnormal  capacity. 
To  accomplish  this  the  water  must  be  allowed  to  flow  in  very  gently; 
rapid  introduction  will  excite  vomiting  much  before  the  stomach  is  really 
full.  Comparison  of  the  percussion  notes  of  the  fidl  and  empty  stomach 
will  also  enable  one  to  locate  its  borders.  If  these  methods  are  not 
satisfactory  the  stomach  may  be  washed  out  and  then  gently  distended 
with  air  by  attaching  the  bulb  of  a  Davidson's  syringe  to  the  tube. 
Succussion  may  be  obtained  by  sliaking  the  body  of  the  child,  or  clapotage 
by  placing  the  tips  of  the  fingers  of  both  hands  upon  the  epigastrium, 
and  giving  alternate  quick  taps  or  thrusts ;  but  these  signs  are  not  of  value 
alone,  they  may  be  obtained  over  a  normal  organ. 

Diagnosis. — As  already  said,  this  rests  upon  the  physical  signs.  The 
only  probable  source  of  confusion  is  a  dilated  colon,  but  care  in  the  obser- 
vations suggested  above  will  enable  one  todififerentiate  the  two  conditions. 


DISEASES  OF   THE   STOMACH  221 

Prognosis. — Dilatation  of  the  stomach  is  not  in  itself  a  grave  condition, 
although  it  is  difficult  to  correct.  It  may,  however,  prove  a  very  serious 
matter  in  an  infant  attacked  by  severe  disorder  of  the  lungs  or  heart. 
The  pressure  of  a  large,  distended  stomach  may  then  serve  to  greatly 
embarrass  respiration  or  the  action  of  the  heart,  and  may  determine  a 
fatal  issue  in  a  case  where  the  prognosis  would  otherwise  be  good. 

Treatment. — The  treatment  is  practically  that  of  a  chronic  gastritis, 
as  given  above.  Special  care  should  be  taken  to  limit  the  quantity  of 
nourishment  as  much  as  is  consistent  with  proper  nutrition,  to  avoid 
the  use  of  any  articles  of  food  which  might  increase  the  abnormal 
fermentation,  and  to  relieve  the  stomach  of  the  accumulations  of  food, 
mucus,  and  gases.  For  this  latter  purpose  washing  the  stomach  regu- 
larly once  a  day  is,  when  possible,  of  great  value.  As  a  tonic  to  the 
muscular  coat  tincture  of  mix  vomica  is  recommended  in  small  doses, 
as  given  for  chronic  gastritis.  The  ordinary  gastric  sedatives  are  of 
little  value. 

If  there  is  an  underlying  constitutional  condition,  especially  rickets, 
that  should  receive  attention  and  treatment,  so  far  as  is  possible  under 
the  circumstances. 

If  there  is  reason  to  suspect  an  organic  stricture  of  the  pyloric  region, 
an  exploratory  operation  might  be  done,  and  in  any  case  where  palliative 
treatment  had  failed,  if  the  child's  condition  permitted  it,  a  gastro- 
enterostomy should  be  considered  as  offering  a  possibility  of  recovery 
by  providing  better  drainage. 


CONGENITAL  HYPERTROPHY  OF  THE  PYLORUS. 

Since  the  original  observations  of  Landerer  (1879)  and  Maier  (1885) 
called  attention  to  the  occurrence  of  a  congenital  obstruction  of  the 
pylorus,  many  observations  have  been  made  which  serve  to  show  that 
the  condition  must  occur  more  frec^uently  than  has  been  supposed. 
Among  the  most  valuable  recent  contributions  to  the  subject  are  those 
of  Thomson,  of  Edinburgh,  and  Still,  of  London,  to  whom  I  owe  my 
knowledge  of  the  affection. 

Etiology. — This  is  entirely  a  subject  of  theory  at  this  time.  Thomson 
inclines  to  the  view  that  the  hypertrophy  is  produced  by  a  derangement, 
probably  from  faulty  development,  of  the  nervous  mechanism  which 
regulates  the  contraction  and  relaxation  of  the  pylorus  under  appropriate 
stimuli.  As  a  result  of  such  derangement  the  muscle  of  the  pyloric 
sphincter  is  overworked  and  consequently  hypertrophies.  Others  hold 
that  the  condition  is  simply  an  error  in  development.  Ashby  reports  a 
case  in  which  hypertrophy  of  the  pylorus  was  found  in  an  infant  which 
had  been  operated  upon  for  imperforate  rectum.  It  is  to  be  remembered 
also  that  instances  of  complete  closure  of  the  pylorus  by  failure  of 
development  have  been  recorded. 

Pathology. — In  the  normal  infant's  stomach  the  pylorus  is  represented 
only  by  a  slight  thickening  in  the  wall  of  the  tube,  indefinitely  marked 


222 


DISEASES  OF   THE  ALIMENTARY   TRACT 


off  from  the  atljacent  parts.  The  wall  of  the  pylorus,  in  a  normal  infant 
of  five  months,  was  fomid  by  Still  to  measure  1.7  mm.;  in  two,  of  ten 
months,  2.0  mm.  and  2.')  mm.,  respectively.  The  lumen  of  the  pylorus, 
under  one  year.  Still  found  to  admit  a  probe  3.5  to  4  nnn.  in  diameter. 
In  cases  of  conj^enital  hypertrophy  the  pylorus  forms  a  cylindrical  tube 
from  2  to  2.5  mm.  in  length,  with  muscular  walls  of  about  5  nnn.  in 
(lej)th,  and  a  calibre  varying  from  the  normal  to  an  aperture  that  will 
admit  only  the  finest  jirobe  (Fig.  40).  Sometimes  after  the  removal  of 
the  stomach  the  contents  can  hardly  be  pressed  through  the  stenosed 
pylorus.  The  lumen  of  the  sphincter  after  death  will  vary  with  the  degree 
of  spasm  present  at  the  time  of  death.  The  thickened  pylorus  may  form 
a  tumor  which  can  be  felt  during  life.  The  remainder  of  the  stomach 
is  dilated  to  a  greater  or  less  extent  and  may  be  coated  with  thick, 
tenacious  mucus.    The  esophagus  is  dilated  in  some  cases. 

Fig.  40 


Hypertrophic  pyloric  stenosis,  section  through  the  pylorus  anrl  adjacent  duodenum:  M.  mucous 
meinbraue;  ,S' .)/,  submucous  coat;  CAf,  circuliir  niuscuhir  coat;  L  M,  longitudinal  muscular  coat,  £>, 
intesliue.     (Dr.  John  Larkin's  preparation  from  Ur.  Uoruing's  case.) 


Microscopically  the  thickening  of  the  pylorus  is  found  to  be  due  to 
a  great  increase  in  the  muscle  of  the  sphincter.  'Fhc  connective  tissue 
may  also  show  some  increase,  but  not  so  much  as  the  muscle.  The 
mucous  membrane  may  show  some  swelling  and  engorgement,  but  is 
usually  not  greatly  changed. 

Symptomatology. — The  first  .sym])tom  of  this  condition  is  vomiting. 
This  docs  not  begin  immediately  after  birth,  and  is  usually  slight  at  first, 
but  gradually  becomes  more  frerjuent  and  more  severe.  It  may  not 
occur  until  the  infant  is  a  month  old,  l)ut  once  it  begins  it  is  usually 
persistent.  Such  cases,  however,  do  show  a  remission  of  symptoms  for 
a  time,  the  improvement  being  probably  due  to  a  relaxation  in  the 
element  of  spasm,  which  undoubtedly  figures  in  a  degree,  at  least,  in 
these  cases.  The  vomiting  at  first  occurs  some  time  after  the  adminis- 
tration of  food,  but  gradually  the  stomach  becomes  more  irritable,  until 
toward  the  end  any  food  taken  is  promptly  rejected.  "The  vomitus  con- 
sists of  the  food,  more  or  less  modified,  and  mucus;  bile  is  never 
present.     Usually  a  variety  of  foods  is  tried  in  succession,  but  without 


DISEASES  OF  THE  STOMACH  223 

result  so  far  as  the  course  of  the  affection  is  concerned.  The  vomiting 
is  sometimes  very  forcible.  It  seems  to  depend  more  upon  the  quantity 
of  food  than  upon  its  composition.  At  first  only  large  quantities  of 
food  bring  it  on;  later,  smaller  and  smaller  quantities  excite  it.  The 
ordinary  gastric  sedatives  have  no  effect  upon  the  disturbance,  but 
in  some  cases  washing  out  the  stomach  and  giving  the  food  by  gavage 
may  temporarily  arrest  it.  The  infants  suffer  from  all  the  symptoms 
of  chronic  vomiting:  scanty  urine,  constipation,  emaciation,  etc.  The 
question  of  the  operations  of  the  bowels  calls  for  attention.  One  may 
be  told  that  the  infant  is  not  constipated,  as  it  has  a  movement  daily, 
but  observation  will  show  that  these  movements  are  very-  small  and 
contain  little  or  no  food.  Toward  the  end  of  life  the  movements  may 
consist  almost  wholly  of  mucus.  The  abdomen  is  distended  in  its 
upper  part,  particularly  in  the  epigastric  region;  the  remainder  of  the 
abdomen  is  retracted  and  permits  satisfactory  palpation. 

There  are  two  other  physical  signs  of  great  importance:  (1)  The 
presence  of  peristaltic  movements  in  the  dilated  stomach.  It  may 
require  repeated  careful  observations  to  detect  these  peristaltic  waves. 
Whether  they  can  be  excited  by  irritation  of  the  epigastrium,  as 
they  can  be  in  adults,  is  not  known.  (2)  The  presence  of  a  small, 
movable  tumor  in  the  region  of  the  pylorus.  The  mass  formed  by  the 
hypertrophied  pylorus  has  been  both  seen  and  felt  in  some  cases.  This 
sign  should  be  carefully  sought,  as  it  is  practically  conclusive  of  the 
nature  of  the  trouble.  The  course  of  the  affection  is  usually  steadily 
progressive,  although,  as  noted  above,  remissions  do  occur  in  some  cases. 
The  duration  of  life  in  the  fatal  cases  has  been  three  weeks  to  six  months. 

Diagnosis. — The  essential  points  in  the  diagnosis  are  these:  (1)  The 
infant  is  born  healthy,  and,  without  apparent  cause,  begins  to  vomit  at 
within  the  first  few  weeks  of  life.  (2)  The  vomiting  persists  despite 
treatment  or  change  in  the  nourishment  and  the  greater  portion  of  the 
food  is  rejected.  (3)  There  is  constipation  and  the  stools  are  formed 
mostly  of  bile  and  mucus.  (4)  There  is  progressive  emaciation,  (o) 
Peristaltic  waves  are  visible  in  the  dilated  stomach.  (6)  A  small  movable 
tumor  is  visible  or  palpable  in  the  region  of  the  pylorus.  The  last  two 
points  are  apparently  conclusive  of  the  diagnosis.  In  the  absence  of 
both  one  would  feel  great  hesitation  in  venturing  an  opinion,  especially 
in  an  artificially  fed  child,  for  many  of  these,  we  knovr,  vomit  persist- 
ently on  one  food  and  yet  improve  promptly  when  the  food  is  changed. 
In  a  breast-fed  child  the  other  symptoms  would  be  of  much  more 
import. 

Prognosis. — There  is  little  doubt  that  this  condition  is  fatal  in  nearly 
all  cases,  unless  the  stenosis  is  relieved  by  operation.  Finklestein 
reports  three  cases  from  Prof.  Heubner's  private  practice  which  recovered 
under  palliative  treatment.  The  diagnosis  in  these  cases  is  a  little 
uncertain.  Batten  has,  however,  reported  a  case  in  which,  although  the 
infant  was  greatly  emaciated  and  a  tumor  was  observed,  recovery 
followed  without  operation.  The  cases  regularly  end  fatally  within  a  few 
weeks.      Osier  has  resurrected  from  the  earliest  medical   publication 


224  DIS'EASES  OF   THE   ALIMESTARY    TRACT 

of   this  country  an  account  of  a  ca.se  in  wliich  tlic  patient,  a  hoy,  lived 
to  the  afje  of  five  years. 

Treatment. — So  loni^  a.s  the  (Hagno.si.s  i.s  in  doubt  the  condition  should 
be  treated  on  the  hne.s  of  a  chronic  (ra.stritis.  Washintf  out  the  .stomach 
and  feedin<5  the  patient  by  the  tube  seem  to  be  the  measures  of  greatest 
vahie.  If  operation  is  inadvisable  or  is  not  permitted  this  treatment 
may  be  continued,  althougli  our  present  experience  gives  little  reason  to 
hope  for  success.  If  the  thagnosis  is  established  operation  should  be 
urged.  The  question  of  the  exact  operation  to  be  done  lies  between:  (1) 
Gastroenterostomy,  which  is  the  operation  recommended  by  most  sur- 
geons. It  has  been  done  in  10  cases  with  5  cures.  (2)  Pyloroplasty,  which 
has  been  done  in  4  cases,  all  successful.  (3)  Loreta's  operation,  which 
has  been  tried  in  12  cases  with  7  recoveries.  The  number  of  recorded 
cases  is  still  too  small  to  justify  conclusions  as  to  which  operation  offers 
the  best  prospect.  The  question  will  probably  be  decided  by  the  prefer- 
ence of  the  surgeon  undertaking  it.  I'he  most  complete  discussion  of 
this  subject  is  the  article  by  Ashby  in  the  Troifr  des  Maladies  de  I'Enfdnce 
of  Grancher  and  Comby,  1904,  second  edition. 


CHAPTER   XL 

ACUTE  GASTROENTERIC  INFECTIONS. 

The  terminology  employed  in  relation  to  the  acute  diarrheal  dis- 
eases of  children  has  always  been  unsatisfactory.  For  many  years  all 
these  affections  were  thro-^Ti  into  one  great  group  under  the  designa- 
tion of  summer  diarrheas.  This  term  was  given  up  because  the  affec- 
tions in  question  were  not  by  any  means  limited  to  summer,  and  also 
because  under  one  name  were  included  diseases  of  evidently  different 
etiology,  lesions,  and  symptoms.  The  attempt  was  then  made  to 
classify  these  several  afPections  on  the  basis  of  their  anatomical  lesions. 
Only  greater  confusion  resulted,  for  it  was  soon  found  that  this  led  to 
meaningless  subdivision,  many  varied  lesions  being  found  to  be  asso- 
ciated with  the  same  clinical  symptoms,  so  that  in  order  to  reach  a 
.satisfactory'  classification  an  autopsy  was  required  in  everv^  case.  Inas- 
much as  the  use  of  infected  or  impure  milk  is  the  most  frequent  appar- 
ent cause  of  these  disorders,  and  especially  as  the  phenomena  of  one 
group  at  least  of  the  cases  are  identical  with  those  produced  by  certain 
proteid  poisons,  known  to  be  developed  in  milk  by  bacterial  action, 
Vaughan,  of  Ann  Arbor,  and  others  have  proposed  to  classify  all  these 
acute  gastroenteric  infections  under  the  title  of  INIilk  Infections.  So 
far  as  the  particular  group  of  cases  described  as  cholera  infantum  is 
concerned,  there  is  ample  support  for  this  \aew,  but  the  extension  of 
the  conception  to  cover  all  the  cases  in  question  seems  unwarranted. 
In  the  light  of  our  present  knowledge  it  seems  probable  that  there  are 
other  means  of  contagion  quite  as  important  as  milk.  Xo  one  scheme 
has  been  found  to  meet  the  needs  of  the  situation.  The  hope  was 
entertained  that  when  the  etiolog'ical  factor  in  these  several  diseases 
was  discovered  we  would  be  able  to  classify  them  more  simply  and 
satisfactorily  on  that  basis.  The  investigations  of  the  last  two  years 
have  apparently  established  the  Shiga  bacillus  in  this  relation  to  a 
large  number  of  the  acute  diarrheas  of  childhood,  but  for  the  present 
these  investigations  have  added  still  further  to  the  prevailing  confusion. 
Instead  of  finding  that  this  bacillus  is  the  cause  of  a  certain  definite 
group  of  lesions  in  the  gastroenteric  tract  or  is  associated  with  disease 
of  a  definite  clinical  type,  we  find  that  it  occurs  with  lesions  varying 
from  the  mildest  catarrhal  inflammation  to  a  croupous  inflammation 
and  severe  ulceration,  and  also  that  the  clinical  types  of  disease  in 
which  the  bacillus  occurs  are  equally  varied.  The  situation  is  still 
further  confused  by  reason  of  the  fact  that  as  the  Shiga  bacillus  was 
originally  identified  in  relation  to  adult  dysenteries,  investigators  have 
taken  to  applying  the  term  dysentery  to  the  diarrheal  diseases  of  child- 
15  '  (  225  ) 


226  DISEASES  OF   THE  ALIMENTARY    TRACT 

hood  in  which  the  l)acinus  is  found,  ahhougli  many  of  these  diarrheas 
have  not  the  chnical  symptoms,  tlie  presence  of  blood  and  mncus  in 
the  stools,  with  which  we  have  all  been  accustomed  to  associate  the 
term.  Furthermore,  the  term  dysentery  has,  for  some  years,  not  been 
in  use  in  writings  dealing  with  diseases  of  children,  or,  when  used,  it 
has  been  limited  to  the  colitis  excited  by  the  presence  of  ameba*.  Alto- 
gether, therefore,  the  situation,  as  it  confronts  us  at  the  present  time 
is  a  ver}'  complicated  one,  antl  I  have  thought  best  to  follow  the  classi- 
fication of  Holt,  which  is  familiar  to  most  of  us,  is  consistent  with  itself, 
and  is  the  most  satisfactory  at  present  known  to  me,  rather  than  to 
attempt  a  new  classification  which  could  only  be  tentative. 

The  general  causes  of  the  diarrheal  diseases  of  infancy  and  child- 
hood have  already  been  discussed.  In  the  present  chapter  we  are  to 
deal  with  those  acute  diarrheal  affections  which  are  especially  com- 
mon in  summer  and  which  are  now  admitted  to  be  due  to  bacterial 
infection;  not  that  these  affections  are  by  any  means  limited  to  the 
summer,  for  they  do  occur  from  time  to  time  during  the  winter,  but 
every  summer  in  these  latitudes  is  marked  by  a  wave  of  these  diseases, 
which  might  be  justly  called  an  epidemic.  The  wave  begins  when  the 
daily  atmospheric  temperature  reaches  or  surpasses  an  average  of  00°  F., 
such  temperature  being  necessary  to  the  general  growth  and  diffusion 
of  the  bacteria  concerned,  and  continues  until  the  falling  temperature 
of  late  SeptemlxT  or  the  first  of  October  puts  an  end  to  this  condition. 
Ordinarily,  the  wave  begins  in  June,  early  or  late,  according  to  the 
temperature  conditions,  rises  rapidly  to  a  maximum  in  July,  continues 
high,  but  with  variations,  during  July  and  August,  and  gradually  sub- 
sides during  the  latter  part  of  August  or  in  September.  The  amount  of 
rainfall  or  the  humidity  seems  to  exercise  no  definite  influence  upon  the 
course  of  the  outbreak.  It  must  not  be  understood  that  the  activity  of 
bacteria  is  the  only  factor  in  the  production  of  these  diseases.  The 
bacteria  are  admitted  in  most  cases,  at  least,  with  food,  most  especially 
with  milk.  The  ways  in  which  milk  becomes  infected  are  therefore 
of  the  greatest  importance  in  the  spread  of  these  diseases.  Practically, 
the  only  pathogenic  organism  known  to  occur  with  any  frequency  in 
milk  as  it  leaves  the  cow's  udder  is  the  tubercle  bacillus.  Certain 
varieties  of  streptococci  are  regularly  found  in  all  milks,  but  their 
pathological  importance  is  disputed.  The  harmful  infections  and 
resulting  changes  in  the  milk  occur  after  it  leaves  the  cow's  udder, 
either  in  the  process  of  milking,  in  transportation,  keeping,  or  prepara- 
tion for  feeding,  or  in  the  feeding  process  itself.  The  measures  for 
avoiding  infection  in  milking  and  the  keeping  of  milk  have,  of  recent 
years,  been  worked  out  most  carefully,  and  have  proven  efl'ective  in  keep- 
ing down  the  bacterial  content  of  milk.  The  essential  point  is  absolute 
cleanliness  at  every  stage  of  the  process,  secured  by  the  careful  cleans- 
ing of  the  cows'  udders,  the  milker's  hands,  the  sterilization  of  all 
vessels  used,  etc.  The  milk  should  immediately  be  chilled  to  a  tem- 
perature below  50°  F.,  and  kept  below  that  point.  In  the  ])reparation 
of  the  milk  and  the  feeding  of  infants  the  principles  of  asepsis  should 


ACUTE  GASTROENTERIC  INFECTIONS  227 

be  followed  and  even  the  best  of  milk  should  be  pasteurized  or  ster- 
ilized during  the  summer  months.  The  effectiveness  of  these  measures 
in  reducing  the  mortality  from  the  diarrheal  diseases  is  admitted  by  all. 
As  in  any  infection,  whatever  lowers  the  vitality  of  an  individual  pre- 
disposes to  an  attack,  so  in  this  relation  bad  hygiene,  constitutional  dis- 
ease, and  especially  any  previous  disorder  of  the  alimentary  tract  are 
to  be  regarded  as  factors  of  importance.  These  infections  may  occur  in 
any  of  the  earlier  years  of  life,  but  are  much  more  common  in  infancy. 

In  the  case  of  the  most  acute  and  severe  of  these  disturbances,  cholera 
infantum,  it  seems  highly  probable  that  the  disease  is  produced,  as 
Vaughan  maintains,  not  by  the  presence  of  bacteria  alone  in  the  infected 
milk,  but  also  by  that  of  larger  or  smaller  quantities  of  the  soluble  poisons, 
toxins  or  leucomaines,  that  are  produced  in  culture  media  by  the  growth 
of  bacteria.  It  may  be  that  these  poisons  are  already  present  in  the 
milk,  when  it  is  given,  or  they  may  be  produced  by  the  continued  action 
of  bacteria  after  the  milk  has  been  consumed.  Tyrotoxicon,  a  poison 
of  the  class  first  found  in  cheese,  has  been  isolated  from  a  sample  of 
milk  w^hich  had  produced  a  severe  choleriform  diarrhea  in  a  child. 
This  tyrotoxicon,  says  Vaughan,  will  in  animals  produce  the  symptoms 
and  lesions  of  cholera  infantum,  ^"arious  other  toxins  have  been 
isolated  from  cultures  of  bacteria  wdiich  have  been  found  in  the  intes- 
tine in  cases  of  acute  diarrheal  disease  and  have  been  proven  patho- 
genic in  animals.  In  Vaughan's  opinion  these  toxins  are  probably  as 
numerous  as  the  bacteria  that  produce  them.  The  suddenness  of  the 
onset  of  cholera  infantum  in  many  cases  in  children  previously  well, 
the  resemblance  of  the  symptoms  to  those  produced  by  any  acute 
irritant  poison,  such  as  arsenic,  the  relatively  rapid  subsidence  of  the 
symptoms  and  recovery  of  the  patient  certainly  support  the  idea  that 
it  is  these  toxins  rather  than  the  bacteria  themselves  which  are  the 
immediate  and  direct  agentt;  in  this  disease.  The  conception  certainly 
seems  to  explain  the  difference  both  in  symptoms  and  in  lesions  observed 
between  cholera  infantum  and  the  more  subacute  or  chronic  cases 
comprehended  under  the  term  ileocolitis. 

Bacteriology. — Until  the  recent  discovery  of  the  presence  of  the 
Shiga  bacillus  the  results  of  a  great  deal  of  laborious  w^ork  which 
h^s  been  done  upon  the  bacteriology  of  the  acute  diarrheal  dis- 
orders of  infants  and  children  have  been  very  unsatisfactory.  The 
meconium  of  the  newborn  is  sterile,  but  after  a  few  hours  bacteria 
begin  to  appear  and  increase  rapidly  in  number.  These  are  chiefly 
bacteria  of  putrefaction.  Escherich  found  fairly  regularly  a  sapro- 
phytic bacillus,  a  non-pathogenic  chain  coccus,  and  the  bacillus  sub- 
tilis.  In  the  stools  of  nurslings  after  the  beginning  of  milk  feeding  the 
bacillus  lactis  aerogenes  and  the  bacillus  coli  communis  are  constantly 
found  in  addition  to  many  other  putrefactive  bacteria.  In  all  diarrheal 
conditions  the  numbers  and  varieties  of  bacteria  are  greatly  increased. 
Booker  worked  out  a  considerable  number  of  these,  but  without  being 
able  to  demonstrate  a  specific  relation  between  any  of  the  bacteria 
and  the  conditions  in  which  they  were  found.     Booker,  Baginsky,  and 


228  DISEASES  OF   THE  ALIMENTARY   TRACT 

Esc'lurich  have  laid  especial  empluusis  on  the  abundance  of  strepto- 
cocci in  certain  cases,  and  (icrman  writers  recognize  a  distinct  condi- 
tion of  streptococcic  enteritis,  hut  the  establishment  of  a  distinct 
tvpe  of  tlisease  due  to  streptococci  hjis  not  been  recognized  by  American 
clinicians.  In  1902  Duval  and  Bassett,  })upils  of  Flexner,  working  in 
the  Thomas  Wilson  Sanitarium  near  Baltimore,  were  able  to  demon- 
strate in  the  stools  of  a  considerable  proportion  of  children  suffering 
from  acute  diarrheal  diseases  the  presence  of  the  Shiga  bacillus.  This 
bacillus  was  first  isolated  and  demonstrated  to  be  the  cause  of  epidemic 
dvscntery  in  man  by  Shiga,  a  Japanese  investigator.  I^atcr,  it  was 
found  by  Flexner  and  Strong  and  ^lusgrave  in  the  dysenteries  of  soldiers 
in  the  Philippine  Islands.  It  was  next  found  by  Martini  and  I>enz  in 
Germany,  and  by  a  number  of  investigators  in  our  own  country 
in  isolated  cases  or  localized  (institutional)  outbrealvs  of  dysentery. 
Since  1902  tlie  findings  of  Duval  and  Bassett  has  been  confirmed 
by  further  studies  on  the  part  of  Duval,  Wollstcin,  Rowland  and 
La  F^tra  and  many  others.  Its  presence  is  not  limited  to  any  one  pre- 
viouslv  recognized  clinical  type  of  disease.  It  has  been  found  in  simple 
fermentative  diarrhea  and  in  the  more  severe  types  of  disease  asso- 
ciated with  more  or  less  severe  lesions  of  the  colon  and  lower  part  of 
the  small  intestine,  ileocolitis.  Its  presence  in  the  intestine  has  also 
been  demonstrated  to  be  associated  with  a  specific  agglutinative  reac- 
tion in  the  blood  of  the  patient,  similar  to  the  Widal  reaction  obtained 
in  typhoid  fever.  While  the  Shiga  bacillus  is  found  in  a  considerable 
variety  of  different  clinical  conditions,  it  has  been  demonstrated  with 
greatest  regularity  in  the  diarrheas  attended  with  fever  and  the  pres- 
ence of  mucus  and  blood  in  the  stools;  in  other  words,  the  cases  most 
closely  resembling  the  dysenteries  of  adults.  The  proportion  of  cases 
of  this  kind  in  which  its  presence  can  be  shown  has  varied  remarkal^ly 
in  different  investigations.  The  variations  seem  to  depend,  to  some 
extent,  upon  the  skill  and  experience  of  the  bacteriologist  making  the 
investigation.  Park  maintains  that  in  every  case  of  acute  diarrhea 
of  the  dysenteric  type  (that  is,  with  blood  and  mucus  in  the  stools)  this 
bacillus  should  be  found.  It  is  recognized  that  there  are  at  least  two 
distinct  cultural  varieties  of  the  Shiga  bacillus :  one,  known  as  the  true 
Shiga  bacillus  or  the  alkaline  type,  does  not  ferment  mannite;  the 
other  does  ferment  mannite  and  is  known  as  the  acid  or  "Harris"  or 
"  Flexner-Manila"  type.  The  latter  is  the  type  chiefly  found  in  infantile 
diarrhea  in  New  York.  Quite  a  number  of  instances  of  infection  with 
both  organisms  have  been  reported. 

The  agglutination  reactions  of  the  several  varieties  of  the  organisms 
have  proved  most  confusing,  and  as  the  belief  in  the  causal  relation  of 
tlie  bacillus  to  the  diarrheas  in  which  it  is  found  rests  upon  the  demon- 
stration of  a  specific  reaction  between  the  bacillus  and  the  blood  of  the 
patient,  conservative  bacteriologists  are  not  yet  thoroughly  satisfied 
that  such  a  relation  exists — that  is,  they  do  not  l)elieve  that  the  Shiga 
bacillus  has  })een  proven  to  be  the  exciting  cause  of  these  infantile 
diarrheas  or  dvsenteries.     The  fact  that  the  Shiga  bacillus  has  been 


ACUTE  GASTROENTERIC  INFECTIONS  229 

found  in  some  few  instances  in  normal  stools  has  some  weight  in  the 
argument,  but  we  are  to  remember  that  the  diphtheria  bacillus  is  also 
found  in  normal  throats,  and  yet  no  one  longer  questions  its  relation 
to  diphtheria.  However,  in  view  of  all  these  facts  I  consider  it  best  to 
hold  to  the  accepted  classifications,  limiting  myself  to  a  statement  of 
the  case  of  the  Shiga  bacillus  as  investigations  have  thus  far  revealed  it. 


SIMPLE   GASTROENTERIC   INFECTION   OR   SUMMER 
DIARRHEA. 

Etiology. — As  the  general  causes  concerned  in  the  production  of 
diarrheal  diseases  in  infants  and  children  have  already  been  discussed, 
the  essential  points  may  be  summarized  here.  1.  Age:  From  birth 
through  the  second  year  these  affections  are  common,  and  are  much  less 
frequent  in  later  years.  2.  Bad  hygienic  surroundings,  particularly 
residence  in  the  crowded  tenement  districts  of  our  great  cities.  3. 
Artificial  feeding.  4.  Irregular  and  improper  feeding,  especially  over- 
feeding, and  the  use  of  bacteria-laden  milk.  5.  Hot  weather.  6. 
Bacterial  infection.  The  specific  organism  is  not  known.  Some  regard 
streptococci  or  the  bacillus  proteus  vulgaris  as  the  offending  bacteria. 
Others  think  that  bacteria  normally  resident  in  the  intestine,  such  as 
the  bacterium  lactis  aerogenes  and  the  bacillus  coli  communis,  may, 
under  certain  favorable  conditions,  assume  a  pathogenic  activity. 
Undoubtedly,  a  certain  portion  of  these  cases  are  included  in  the  category 
of  those  produced  by  the  Shiga  bacillus. 

Pathology. — Few  of  the  cases  are  fatal  except  in  those  already  suffering 
from  chronic  affections  of  the  stomach  and  intestines,  the  lesions  of 
which  have  been  confused  with  those  of  the  acute  process.  This  is 
essentially  an  acute  catarrhal  inflammation  of  the  stomach  and  intestinal 
tract.  The  stomach  is  usually  distended  with  gas  and  food.  Its  walls 
are  coated  with  mucus  and  possibly  show  irregular  patches  of  congestion. 
The  upper  part  of  the  small  intestine  is  usually  normal.  The  lower 
ileum  shows  some  congestion  and  a  little  swelling  of  the  mucous  mem- 
brane. Peyer's  patches  may  be  swollen  and  hyperemic.  In  the 
colon  similar  changes  are  found.  The  ascending  and  transverse  colon 
may  be  distended  with  gas.  The  congestion  is  mainly  upon  the  rugae 
and  is  more  marked  in  the  lower  part  of  the  colon  than  above.  The 
solitary  follicles  may  be  swollen  and  their  margins  marked  out  by  a 
zone  of  congestion.  The  mesenteric  lymph  nodes  are  swollen  and  may 
be  slightly  hyperemic.  The  contents  of  the  intestine  are  thin,  watery, 
green  or  yellowish  in  color,  show  undigested  food,  and  are  foul-smelling; 
there  is  usually  but  little  mucus  in  the  feces. 

Symptomatology. — The  symptoms  may  appear  gradually  or  suddenly. 
The  gradual  onset  is  most  often  seen  in  those  who  are  already  suffering 
from  chronic  disorder  of  the  alimentary  tract,  and  are  weakened  or 
marantic  therefrom.  In  these  cases  the  movements  of  the  bowels  become 
more  frequent,  are  at  first  yellow,  later  green,  or  brown  in  color,  and  foul 


230 


DISEASES  OF    THE   ALIMEXTARY    TRACT 


in  odor.  'I'he  patients  have  a  little  fever;  they  are  j)eevi.sh,  fretful,  and 
restless,  espeeially  at  nij^ht.  The  ahdoinen  is  distended  with  jjas  and  the 
infants  suffer  from  pains,  eausinj;  them  to  crv  sharj)ly  at  times  and 
lie  with  the  legs  drawn  up.  \'oiniting  may  oceur  in  these  cases  l)ut  is 
not  marked.  Such  children  lose  weij^ht  rather  7-a])idly,  the  skin  and 
tissues  generally  become  pallid  and  relaxed,  and  UKjreor  less  prostration 
results.  After  two  or  three  days  under  proper  care  the  .symptoms 
subside  and  the  infant  returns  to  its  fomier  condition,  or  if  neglected 
the  symptoms  of  an  ileocolitis  gradually  develop  and  the  disease  runs 
the  protracted  course  characteristic  of  that  condition.  The  sudden 
onset  is  more  often  seen  in  children  previously  well.  The  first  .symptom 
is  usually  vomiting,  and  on  taking  the  temperature  it  is  found  to  be 
elevated,  102°  to  103°  F.,  even  105°  or  10C°  F.  The  vomiting  is  repeated. 
At  first  the  vomitus  consists  simply  of  the  food  present  in  the  stomach, 
then  of  mucus  and  water,  and  later  bile  may  appear.  In  from  four  to  six 
hours  after  the  onset  the  diarrhea  l)egins.  At  first  the  stools  are  yellow 
and   contain   undigested   food,   then   they  become  green,  with   whitish 

Fig.  41 


Temperature  chart  of  a  case  of  enterocolitis  in  a  child  aged  sixteen  months.    Shiga  bacillus, 
acid  type,  isolated  from  stools :  recovery. 

lumps  or  curds;  they  are  often  mixed  with  gas,  and  consequently  frothy. 
The  tongue  is  coated  with  a  white  fur,  the  thirst  is  usually  severe,  and 
the  infants  take  eagerly  whatever  is  offered,  only  to  vomit  promptly 
thereafter.  Restlessness  and  fretfulness  are  marked,  particularly  at 
night.  In  the  severer  cases  the  temperature  may  reach  103°  to  H)o°  F., 
the  vomiting  and  purging  be  quite  persistent,  but  they  have  not  the 
serous  character  seen  in  cholera  infantum,  and  the  extreme  prostration 
and  severe  nervous  symptoms  of  this  affection  are  wanting.  The  stools 
may  be  very  frefpient,  even  twenty  being  passed  in  a  day,  and  often  with 
pain.  ]\Iore  or  less  erythema  and  excoriation  appear  about  the  anus  and 
buttocks  from  the  irritation  of  the  discharges.  The  stools  are  usually 
large,  are  expelled  with- considerable  gas,  are  gray,  green,  or  brown  in 
color,  and  foul.  Weight  is  lost  rapidly,  the  prostration  may  be  marked, 
the  fontanel  becoming  depressed  and  the  eyes  sunken,  the  pulse  rapid 
and  feeble,  the  muscular  relaxation  marked.  The  temperature  is  usually 
quite  irregular,  varying  from  90°  to  103°  F.,  or  even  higher.  Often  after 
a  large  evacuation  the  temperature  will  fall  several  degrees.  The 
abdomen  continues  distended  and  full  from  the  presence  of  gas  in  the 


ACUTE   GASTROENTERIC  INFECTIONS  231 

Intestines.  After  two  or  three  days  of  severe  symptoms  improvement 
may  be  shown  by  less  fever,  less  frequent  vomiting,  and  less  prostration. 
The  diarrhea  usually  continues  for  some  days.  Progress  toward 
recovery  may  be  rapid,  but  may  be  interrupted  by  any  new  mistake  in 
feeding  or  by  the  occurrence  of  very  hot  weather.  In  most  cases  the 
symptoms  gradually  subside  and  the  infants  make  good  recovery.  In 
some  instances  after  the  beginning  of  improvement,  the  fever  persists, 
the  diarrhea  continues,  mucus  and  perhaps  blood  appear  in  the  stools, 
and  the  cases  run  the  course  of  an  ileocolitis. 

In  the  worst  cases  or  in  infants  already  weakened  by  preceding  disease 
no  improvement  occurs;  the  fever,  vomiting,  and  diarrhea  continue;  the 
infant  passes  into  a  condition  of  stupor  and  dies  from  exhaustion  or 
convulsions. 

Diagnosis. — It  is  well  known  that  almost  any  acute  disease  in  a  child 
may  begin  with  acute  gastroenteric  symptoms,  especially  scarlet  fever, 
pneumonia,  and  tonsillitis.  The  diagnosis  of  ileocolitis  must  be  reached 
by  the  absence  of  any  of  the  characteristic  signs  of  these  diseases. 

It  is  more  difficult,  as  a  rule,  to  tell  in  just  which  category  of  the  acute 
disturbances  of  the  alimentary  tract  to  classify  a  given  case.  From  acute 
indigestion  the  cases  are  distinguished  by  their  occurrence  in  summer, 
higher  fever,  greater  prostration,  severer  vomiting  and  diarrhea,  and 
the  abundant,  foul-smelling  stools.  IVIany  of  the  cases  still  more  closely 
resemble  those  classified  as  ileocolitis,  and,  as  has  been  said,  many  go 
on  to  develop  the  lesions  and  symptoms  of  that  condition.  As  a  rule, 
the  cases  of  acute  gastroenteric  infection  are  shorter  in  duration, 
improvement  coming  within  three  oi-  four  days,  but  the  chief  difference 
lies  in  the  absence  from  the  stools  of  the  blood  and  mucus  characteristic 
of  the  ileocolitis.  Some  days  of  careful  observation  may  be  required  to 
determine  the  diagnosis. 

Prognosis. — Even  in  severe  cases  the  prognosis  is  usually  good.  The 
prospect  of  recovery  is  most  influenced  by  the  age  of  the  child,  the 
severity  of  the  onset,  and  the  promptness  with  which  appropriate  treat- 
ment is  instituted.  An  acute  gastroenteric  infection  occurring  in  an 
infant  under  three  months  of  age  or  in  an  older  child  already  weakened 
by  previous  disease  is  often  fatal.  Many  of  them  succumb  at  the  very 
onset;  still  more  die  in  the  course  of  this  affection  itself  or  from  a  resulting 
ileocolitis.  Prompt  and  effective  treatment  often  plays  an  important 
part  in  deciding  the  outcome. 

Prophylaxis. — This  infection  belongs  especially  to  the  summer  season, 
but  is  favored  by  any  disturbance  in  the  digestive  tract.  The  hygiene 
and  diet  of  infants  during  the  summer  should  be  regulated  with  especial 
care.  They  should  be  kept  out-of-doors  practically  all  day  long,  but 
they  must  not  be  exposed  to  the  direct  heat  of  the  sun.  It  is  best  by  all 
means,  when  possible,  to  send  infants  and  children  from  the  city  to  the 
country  for  the  summer  months.  There  is  no  reason  to  prefer  the 
sea-side  to  the  mountains,  except  that  the  changes  of  temperature  from 
day  to  night  are  usually  less  sudden  and  severe  at  the  sea-shore  than 
in  the  higher  altitudes.     Either  is  vastly  better  than  the  stifling  heat  of 


232  DISEASES  OF  THE  ALIMENTARY   TRACT 

an  overcrowded  city.  Care  should  always  l)c  taken  on  cool  nights  to 
see  that  infants  are  properly  covered.  If  circumstances  do  not  permit 
a  prolonged  stay  away  from  the  city,  the  daily  excursions  that  are  con- 
ducted by  so  many  charitable  organizations  in  large  cities  may  be  of 
service. 

Infants  and  children  should  be  bathed  frequently  during  the  summer, 
at  least  once  a  day,  and  better  twice,  morning  and  evening.  They 
should  always  be  given  water  in  al)undance,  cooled  but  not  iced.  Even 
the  youngest  infants  will  take  water  with  advantage  on  hot  days.  If 
possible  to  keep  an  infant  on  breast-feeding  during  the  summer  it  is 
always  best  to  do  so.  Weaning  should,  unless  absolutely  necessary,  be 
avoided  until  the  fall.  If  artificial  feeding  is  resorted  to,  milk  of  assured 
purity  should  be  used,  and  care  should  be  taken  that  it  is  as  fresh 
as  possible.  City  milk  is  often  two  days  old.  Whatever  the  milk, 
pasteurization  or  sterilization  should  be  employed  during  the  sum- 
mer months;  in  the  latitude  of  New  York  this  is  best  done  from 
]\Iay  1st  until  October  1st.  Of  next  importance  is  care  not  to  over- 
feed. Children,  especially  infants,  should  never  be  urged  to  feed  fluring 
hot  weather.  I^ack  of  desire  for  food  is,  as  a  rule,  good  evidence  that 
food  should  not  be  given.  Greater  care  than  usual  should  l)e  taken  in 
making  any  increases  in  the  strength  of  the  food.  On  very  hot  days 
it  is  best  to  reduce  the  amount  of  each  feeding  one-third  or  more  and 
supply  the  deficiency  by  the  addition  of  water.  Every  disturbance  of 
digestion  should  be  regarded  seriously  and  effort  made  to  correct  it, 
lest  it  open  the  way  to  serious  infection. 

Treatment.  Hygienic. — Fresh  air  is  of  the  utmost  importance  in  the 
management  of  these  cases.  The  patients  should  be  kept  in  the  open 
air,  but  protected  from  the  sun,  all  day  long,  and  doubtless  many  would 
do  better  if  their  nights  also  were  spent  out-of-doors.  But  care  must  be 
taken  during  the  hours  of  the  night  to  see  that  the  infants  are  sufficiently 
covered  to  keep  the  feet  warm.  If  it  is  possible,  it  is  most  advantageous 
to  send  these  cases  promptly  to  the  country,  either  mountains  or  sea-side, 
so  long  as  they  get  fresh  air.  Twice  a  day  the  infants  should  be  sponged 
with  cold  water  and  the  skin  kept  carefully  powdered  around  the  but- 
tocks and  genitals  to  prevent  the  excoriation  which  is  so  common. 
Diapers  should  be  changed  promptly  when  soiled  and  should  be  dis- 
infected, either  by  antiseptic  solutions  or  })y  boiling,  l)efore  being  used 
again.  There  is  little  evidence  of  the  transmission  of  the  infection  from 
one  child  to  another,  but  in  view  of  the  abundance  of  bacteria  in  the 
stools  and  the  possibility  that  the  individual  himself  may  be  reinfected, 
disinfection  of  the  diapers  is  advisable.  In  hospitals  it  should  l)e 
insisted  upon.  Quiet  and  rest  should  be  secured  as  far  as  possible. 
Where  many  of  these  children  are  gathered  in  large  hospital  wards  the 
crying  and  fretting  of  one  or  more  will  keep  all  awake  and  interfere 
with  the  sleep  that  is  of  great  importance  to  recovery. 

Dietetic. — In  nurslings.  The  infant  should  be  taken  from  the  breast 
and  kept  from  it  until  the  acute  symptoms  of  the  onset  have  subsided. 
If  the  vomiting  is  marked  it  is  best  not  to  attempt  feeding  at  all  for 


ACUTE  GASTROENTERIC  INFECTIONS  233 

twenty-four  hours.  Boiled  water  should  be  given  cold  in  small  (tea- 
spoonful)  quantities,  until  tolerance  shows  that  more  can  be  retained. 
If  feeding  seems  to  be  necessary  albumen-water  or  whey  may  be  given, 
one  to  two  tablespoonfuls  every  two  hours,  not  oftener,  until  the  tem- 
perature is  lower  and  the  vomiting  and  diarrhea  somewhat  lessened. 
Then  the  breast  may  be  allowed,  the  quantity  taken  being  restricted  by 
limiting  the  nursing  time  to  three  or  four  minutes  at  first  and  permitting 
nursing  only  once  in  four  hours,  with  whey  or  albumen-water  in  the 
interim.  Water  may  be  given  at  any  time  to  relieve  thirst,  unless  its 
administration  provokes  vomiting.  If  return  to  the  breast  aggravates  the 
symptoms,  nursing  should  be  entirely  stopped  and  will  probal)ly  have  to 
be  given  up  entirely.  A  second  trial  may  be  made  after  another  interval 
of  twenty-four  to  forty-eight  hours'  feeding  with  the  whey  or  albimien- 
water,  and  if  this  results  badly  there  should  be  no  hesitation  in  changing 
to  artificial  feeding  entirely  or  securing  a  healthy  wet-nurse.  If  breast 
feeding  has  to  be  abandoned  the  case  will  have  to  be  treated  exactly 
as  though  artificial  feeding  had  been  originally  employed;  that  is,  in 
attempting  to  feed  we  should  begin  with  very  dilute  foods,  then  use 
cows'  milk  highly  diluted,  and  so  on. 

In  the  artificially  fed  we  begin  by  cutting  off  all  food,  especially 
milk,  for  twenty-four  or  forty -eight  hours.  The  preparations  known  as 
liquid  peptonoids  or  panopepton,  diluted  three  or  four  times,  and  given 
cold  in  4.0  c.c.  (teaspoonf ul )  doses  every  hour  or  two,  will  often  be 
retained  better  than  anything  else.  While  of  doubtful  food  value,  their 
considerable  percentage  of  alcohol  (about  20  per  cent.)  makes  them 
valuable  as  stimulants.  We  may  test  the  retentive  power  of  the  stomach 
with  these  and  then  try  weak  foods  of  greater  value — albumen-water, 
whey,  chicken-broth,  beef-juice,  malted  or  cereal  milk,  and  dextrinized 
barley-gruel.  Whatever  food  is  given  must  be  tried  in  small  quantities, 
about  one-half  what  the  infant  would  ordinarily  receive,  and  in  the  case 
of  such  foods  as  malted  milk,  in  a  strength  suited  to  the  digestion  of  an 
infant  half  the  age  of  the  patient,  or  even  less.  Albumen-water  or  whey 
is  usually  borne  fairly  well,  even  by  the  youngest  infants.  To  an  infant 
of  three  months  we  may  begin  with  15  c.c.  to  30  c.c.  (one-half  to  one 
ounce)  every  two  hours,  and  increase  the  quantity  to  two  or  three 
ounces  gradually.  Fresh  beef-juice  may  be  given  in  quantities  of 
15  c.c.  to  30  c.c.  (one-half  to  one  ounce)  as  an  alternative  feeding; 
special  care  is  needed  that  this  is  prepared  from  untainted  meat. 
The  greatest  diflSculty  may  be  experienced  in  some  cases  in  getting 
the  infant  to  take  any  food  whatever,  and  we  may  have  to  try  one 
food  and  then  another  before  we  find  one  that  the  infant  will  take 
and  digest.  The  condition  of  the  stools  as  well  as  the  course  of 
other  symptoms  must  be  watched  for  guidance  as  to  the  digestion 
and  assimilation  of  the  foods  given.  Beef-juice  and  albumen-water 
may  give  offensive  stools.  After  one  or  more  of  these  substitutes  have 
been  used  for  several  days,  if  the  temperature  has  subsided  and  the 
stools  have  shown  definite  improvement,  both  in  number  and  in  their 
consistency,  milk  may  be  tried.     If  whey  has  been  found  to  agree  it  is 


1>;M  diseases  OF   THE   AU.MES'TARY    TRACT 

usiiallv  lu'st  to  U^fjiu  the  administrutioii  of  milk  hy  atidini;  a  sinj;le  tea- 
spoonful  of  milk  to  rarh  ftt'diiiu;  i»f  w  lu'V.  If  milk  alone  Is  to  Ik'  usitl  it 
nm>(  Ite  ^iviii  aC  tiiM  diluted  with  many  time.>  it>  vtilume  t>f  a  .">  jkt  eeut. 
solution  of  suj;ar  of  milk,  'riuis,  for  an  infant  under  thnv  months  of 
ai::e  we  may  use  a  ililution  with  nine  parts  of  sueh  sujrar  solution,  which 
wi»uld  i;ive  us  a  milk  mixturt'  eoutainim,'  approximately  0.4  fat,  ').4  jht 
eent.  suijar.  and  0.\  proieid.  If  this  is  well  Imrne  the  dilution  may  Ih' 
dimiuisju'tl  gradually  to  ijive  us  eonsianily  ineiva>inu:  jH'nenta^'es  i»f  fat 
and  proteid.  This  may  Ix'  aettmiplishetl  hy  sulvstitutinj;  a  (»  jkt  i-ent.  or 
S  JHT  eent.  eieaiu  for  the  plain  milk  and  diluting  as  U'fon'.  If  plain  milk 
is  found  to  he  Mt»t  tlii^'stetl  the  milk  may  Ih»  jx^ptonizetl.  Holt  rt-eom- 
mends  jH'pti>ni/ation  for  as  umeh  as  two  hours  to  ensurv  the  eomj>lete 
dii^'stion  of  the  proteitl.  Wherever  jxvssihle  it  Ls  preferable  to  use  dilutt*tl 
milk  or  crt»ain,  in  onler  that  we  may  know  exactly  the  etMnjx^sition  of 
the  ftHHl  ijiveu  ami  n'jjulate  our  inervases  at>ei>nlinf;ly.  Then'  Ls  no 
tlouhi  thai  in  nuvst  instam>es  in  infants  the  dilution  of  milk  with  a  etTt'al 
water,  harlev-water  preferably,  renders  it  mort'  «li«^'stihle.  esjxtially  if 
the  ivreal  Ih'  dextrinizixl  by  the  addition  of  one  of  the  diiistatie  ferments. 
If  we  ean  onee  get  the  inhuits  to  digest  even  small  i|uantitit>s  of  milk 
it  is  usuallv  jxis^sible  by  veri'  ijradual  inervasos  to  get  them  to  g:un  in 
weiiiht.  cVur  tirst  aim  should  Ih»  to  stvurt'  the  t^omfort  of  the  infant,  by 
t»i\  ing  a  fixnl  that  ean  Ik*  digesteik  'l\x>  grvat  luiste  iti  making  ineri'itses 
in  the  strength  of  the  fiKxl.  in  onler  to  stvun*  an  inert^jise  in  weight, 
w  ill  onlv  rt^ult  in  increasing  the  dlsturlxuu^  ami  delaying  reci>very.  It 
mav  Ih'  ntH^'s.sary  to  Ih»  i\mtent  with  little  or  no  gjun  until  tlie  return 
of  iix>ler  weather  imprvm^s  the  atiuivsplurie  i\>nditions  and  revives  the 
jvitient. 

In  anv  ease  the  prv^ress  is  usually  slow  and  marketl  hy  more  or  less 
frrHpient  relapst>s,  sometinu^  due  to  changes  in  the  fixxl,  again  to 
ii\crr*ase  in  the  atmospheric  temjxTstture.  or  other  unfavon»ble  ixin- 
tliiious.  Whenever  any  fixxl  is  given  a  trial,  .sevend  days  are  nsuallv 
rtHpiirtsl  Ufort*  we  can  tell  tlefinitely  whetlur  or  not  it  is  Uing  digestrtl; 
changes  should  not  l>e  made  tix»  rapi«lly.  Many  a  case  that  liH>ks  hojx^ 
less  mav  Ix'  savtNl  if  a  gixxl  wet-nurse  can  Ix*  seinm^l.  If  breiisl  milk 
can  lx»  iligx^sttNl.  pnxgress  will  lx»  more  rapid  and  satisfactory  than  with 
anv  other  form  of  ftvtling.  I'nforttmately  it  is  dithculf  to  stvure  tiie 
dt>sirtHi  ntirse  under  any  etunditioiis,  and  espeeially  s*>  when  the  infant 
Is  desjx'rately  sick. 

.\/rt^Voi»»i/.— In  the  beginning  of  treatment  it  is  Ix'st  to  give  a  dose 
of  calojnel  or  csustor  oil.  If  the  stomach  is  not  tlisturlxHl  castor  oil  is 
prefcriible,  AX)  c.c,  (1  drachm)  for  a  child  nnder  one  year  of  age.  S.O  c.e. 
^2tlrachms)  for  one  over  a  vear,  and  15  e,e,  {\  oumv)  for  childrtni 
of  thr*v  or  four  wars.  In  cases  where  \x>miling  ha-*  Ixvn  lejx^aictl, 
cjistor  oil  will  tisiially  Ix^  rejtvttMl;  we  then  give  (),l>lW>  gm.  (a  gnun)  of 
calomel  in  dividtnl  tWes;  tU)l  to  IV015  gm.  (gr.  |  to  gr.  \)  everx  hour 
until  O.lVw^  gm.  <l  grain)  is  ta)«n,  to  a  child  of  one  year;  0.1  :i  gm.  (2 
grj»insl|  Is  givei^  in  the  same  way  to  older  children,  l^ter  in  the  tx>urse 
of  the  disease,  whenever  there  is  an  incieast*  in  the  symjWoms,  csjxh  iaily 


ACUTE  CASTROENTERW  INFECTIONS  235 

if  the  stools  hocomt>  more  frecjiuMit  and  show  more  uiuH^vsted  food,  it 
is  best  to  repeat  the  dose  of  oil  or  calomel,  la  any  case"  when  a  ehaiii>-e 
of  food  seems  desirable  it  is  best  to  clear  the  intestim^  in  this  way.  For 
the  contrt)l  of  the  diarrhea  itself  an  almost  endless  list  of  intestinal 
antiseptics  has  been  brou»-ht  forward  and  each  has  fonnd  more  or  less 
advocacy;  bnt  two  or  three  have  proven  suffici(>ntlv  satisfactorv  to 
continue  to  enjoy  otMu>ral  usaox\  Bismuth  undoubtiHlly  holds  th(>  first 
place,  ^riie  snbuitrat(%  subcarbonate,  salicylate,  and  subgallate  hav(>  all 
l)een  reconunended.  The  subnitrate  and  subcarbonate  are  given  in 
large  doses,  0.()5()  gm.  (10  grains)  or  more  every  two  hours  after  the 
feedings,  Tht>  subgallate  or  salicvlate  in  doses  of  0.130  to  0.200  irm. 
(two  to  four  grains)  evt>ry  two  hoiu's,  after  feedings.  Tluvse  may  be 
given  in  powders,  but  for  administration  to  infants  or  young  children 
it  is  better  to  suspend  them  in  some  such  {)rt\scri[)tions  as  the  following: 

it— Bismuth,  subnitratis 8.0  gm.  (.''>ij). 

AcaciiO 2.0    "  (gr.  xxx). 

Tmgacanth 2.0    "  (gr.  xxx). 

Aquas ad    rJO.O  c  c  (3iv).— M. 

Sig.— 4-8  c.C.  (ouo  oi'  two  loaspoonfiils)  every  two  hours. 

Or, 

ti— BisiButh.  salicylatis 4.0  giu.  (SJ). 

Acaclse 2.0    "  (gr.  xxx). 

Tragacauth 2.0    "  (gr.  xxx). 

Aqust) ad    r20.0D  c.c.  (*Siv).— M. 

Sig. — ^^1-8  e.c.  (one  or  two  loaspooiUuls)  every  two  Ijouvs. 

Of  these  undoubtedly  the  subnitrate  is  still  j>rcferrc(l  and  seems  to 
be  as  useful  as  any.  I.arge  doses  are  required  to  be  of  any  s(i\  !(•(>. 
Sulol  also  is  oft(Mi  emj)loy(Hl  in  doses  of  0.12  to  0.2  I  gm.  (2  to  4  grains) 
every  four  hours. 

4t-Saloi 4  0gm.  (Sj). 

01,  olivte ic.o  c.c.  (5iv). 

Acacias 2.0  gm.  (gr.  sxx). 

Traga(!anth 2,0    "  (gr.  xxx). 

Aqute ad  120,0  c.c.  (.'^iv).— M, 

Sig,— 4-8  c.c.  (one  to  two  teaspoonfuLs)  every  tour  hours. 
(The  oUve  oU  is  ueces-sary  to  dissolve  the  salol.) 

Salicylate  of  soda  may  be  used  in  .solution. 

it— Sodll  hyposuli)hitis 0.75  gm,  (gi'.  x). 

SwUl  sallcylatls 4  to  8.00   "  (.%j  to  lj>. 

AquiB  laenthas  pip,  ,       ,        .       ,     ad       l2o.00c,c.  (3lv).— M. 

Sig.— 4-8  c.c.  (oue  to  two  teaspooufuls)  (^very  I'oiu-  hours. 

The  hv|)osiilphitc>  of  sodium  is  added  only  to  prev(>nt  the  mixture 
changing  color  and  btH'oming  black. 

The  more  complex  anti.septics,such  as  /^/-naphthob/V-naphthol  bismuth, 
tannigen,  etc.,  have  not  found  any  general  acceptance,  'i'he  simpl(M'  our 
prescriptions  can  l>e  kept  in  these  conditions  the  less  irritating  the  medi- 
ciiH-s  will  l)e,and,  as  a  rule,  the  better  will  they  be  l)orne.  Any  mcdiciii(> 
which  causes  vomiting  should  be  promptly  stop|>ed  lest  it  do  more 
harm  than  good.  ( )ne  of  the  (hHicuU  |)robleras  in  these  conditions  is 
that  of  the  use  of  opium.     h\)v  a  long  time  opiimi  in  some  form  was  added 


230  DISEASES  OF   THE  ALIMENTARY  TRACT 

to  nearly  every  mixture  used.  Lately,  this  has  been  entirely  given  up 
and  opium,  if  administered,  is  given  alone,  the  better  to  regulate  the  <lose 
and  atlministration.  Undoubtedly,  the  diarrhea  ean  be  eheeked  by  the 
use  of  opium  in  any  form,  but  not  always  with  benefit  to  the  patient. 
Opium  should  be  used  only  for  one  of  two  purposes:  (1)  to  relieve  ])ain, 
or  (2)  to  eheek  exeessive  peristalsis  due  to  the  intestinal  irritation  or 
inflammation.  It  is  to  be  remembered  that  the  diarrhea  is  to  some 
extent  a  protective  process,  ridtling  the  system  of  products  of  fermen- 
tation which,  if  retained,  do  harm.  It  is,  therefore,  easy,  by  entirely 
stopping  the  action  of  the  bowel  l)y  oj)ium,  to  do  harm  to  the  patient. 
Opium  is  best  given  either  in  the  form  of  the  camphorated  tincture 
(paregoric)  in  doses  from  five  to  twenty  drops,  repeated  every  one,  two, 
or  three  hours,  until  the  desired  effect  Is  produced.  Small  doses  may 
contribute  much  to  the  comfort  of  a  patient  and  help  to  recovery, 
Dover's  powder  may  be  used  as  a  substitute,  in  doses  of  0.01  to  0.0 1.') 
gm.  (g  to  J  grain),  repeated  in  a  similar  way.  In  severe  cases  Holt 
recommends  morphine  hypoderraically,  O.OOOi)  gm.  (gr.  ywo)  ^^^  ^  child 
a  year  old.  For  great  restlessness  or  in  conditions  where  convulsions 
seem  to  be  threatening,  no  other  remedy  can  be  so  effective. 

Stimulants  will  be  required  in  many  cases  to  meet  the  prostration 
and  exhaustion  of  the  disease.  Alcohol  in  the  form  of  whiskey  or  brandy 
is  usually  best.  Either  may  be  given  to  the  amount  of  15  to  30  c.c. 
(t  to  1  ounce)  daily  to  a  cliild  one  year  old.  Each  dose  must  be  given 
diluted  from  four  to  six  times  with  water.  It  is  best  to  give  small  quan- 
tities, say  10  to  30  drops,  every  hour  or  two.  INIuch  larger  amounts  can 
be  given  if  necessary.  In  cases  of  severe  vomiting  ice-cold  champagne 
may  be  retained  when  any  other  form  of  alcohol  is  vomited.  It  mav  be 
given  in  teaspoonful  doses,  diluted  two  or  three  times  with  water.  For 
extreme  prostration  whiskey  may  be  given  hypodennically,  10  to  1.) 
drops  diluted  with  sterile  water,  or  we  can  resort  to  hypodermoclysis, 
as  described  on  page  240. 

Lavage  of  the  stomach  and  colon  may  both  be  of  great  service.  In 
the  early  stages,  washing  out  the  stomach  will  serve  the  purpose  of 
emptving  it  of  some  of  the  toxins;  it  will  also  check  the  vomiting,  and  it 
may  he  resorted  to  at  any  time  when  vomiting  is  frequent.  Plain  water, 
normal  salt  solution,  or  4  gm.  (1  drachm)  of  sodium  bicarbonate  to 
.oOO  c.c.  (1  pint)  of  water  are  to  be  iLsed  for  this  purpose.  In  most  instances 
it  is  advisable  to  leave  lo  to  .30  c.c.  (1  or  2  ounces)  of  fluid  in  the 
stomach  to  appease  the  thirst.  It  will  often  be  retained  under  these 
conditions  when  rejected  in  any  other  way.  Lavage  of  the  colon  serves 
to  remove  decomposing  and  irritating  material  from  the  bowel.  It 
should  always  be  employed  at  the  outset  and  mav  be  repeated  three  or 
four  times  in  twenty-four  hours,  later  once  or  twice  daily  will  l)e  sufficient. 
The  temperature  of  the  water  used  should  be  about  Ho°  to  90°  F. 

It  is  to  be  remembered  that  collapse  can  be  increased  by  rectal  irriga- 
tion, and  care  should  l)e  taken  in  weakly  children  to  raise  the  tem- 
perature of  the  water  and  shorten  the  duration  of  the  process.  Each 
washing  is  to  be  continued  until  the  folon  is  thoroughly  emptied  and 


ACUTE  GASTROENTERIC  INFECTIONS  237 

the  water  returns  clear.  The  body  temperature  will  be  lowered  in 
proportion  to  the  temperature  of  the  irrigation,  and  these  irrigations  may 
be  regularly  employed  as  one  means  of  controlling  high  temperatures 
in  these  conditions.  The  irrigation  should,  as  a  rule,  be  stopped  when 
the  temperature  returns  to  normal,  otherwise  the  washing  may  prove 
sufficiently  irritating  to  the  colon  to  continue  the  diarrhea  some  time 
lontjer  than  would  otherwise  be  the  case. 

When  lavage  of  the  stomach  cannot  be  employed  large  draughts  of 
water  may  be  given,  the  resulting  vomiting  being  depended  on  to  clear 
the  stomach.  If  the  vomiting  has  already  been  repeated  or  excessive, 
washing  or  the  giving  of  much  water  may  be  dispensed  with. 
The  active  treatment  of  these  cases  may  be  summarized  thus: 
1.  Stop  all  feeding  for  twenty-four  to  forty-eight  hours,  allowing 
water  freely.  2.  Clear  the  stomach  and  intestinal  tract  by  washing 
stomach  and  colon  and  by  giving  calomel  or  castor  oil.  3.  When  feeding 
is  resumed  adapt  it  to  the  digestive  power  of  the  patient.  4.  For  the 
control  of  the  diarrhea  rely  mainly  on  the  feeding.  Subsidiary  measures 
are:  (a)  washing  out  the  colon  daily;  (6)  the  use  of  intestinal  antiseptics 
or  antifermentatives.  5.  ]\Iake  all  increases  in  food  cautiously,  watching 
especially  the  general  condition  of  the  patient  and  the  condition  of  the 
stools  as  guides.  6.  Attention  to  the  details  of  hygiene  and  fresh  air 
and  quiet  are  most  valuable  aids  to  our  other  measures. 


CHOLERA  INFANTUM. 

Etiology. — The  general  considerations  in  this  regard  have  already 
been  stated.  True  cholera  infantum  is  a  disease  of  children  under  the 
age  of  three  years.  It  is  practically  unknown  in  breast-fed  children. 
It  occurs  regularly  at  the  height  of  summer  and  is  not  seen  during  the 
winter  months.  The  view  that  the  disease  is  an  acute  poisoning  with 
the  toxins  produced  in  milk  by  bacterial  growth  seems  to  me  to  best 
meet  the  facts  of  the  case.  These  toxins  are  probably  present  in  the 
milk  at  the  time  of  ingestion,  but  may  also  be  elaborated  within  the  body. 
The  specific  organism  or  organisms  are  not  yet  known. 

Pathology. — The  symptoms  of  the  disease  are  out  of  all  proportion  to 
the  lesions  found  present  in  the  body  after  death.  The  bodies  of  the 
dead  are  notably  reduced  in  proportion  to  the  duration  of  the  disease; 
the  abdomen  is  retracted;  the  tissues  are  pale  and  relatively  bloodless; 
the  eyes  are  sunken.  The  lesions  in  the  stomach  and  intestines  are 
surprisingly  slight.  Usually  the  whole  alimentary  tract  is  pale  and 
bloodless,  having  a  washed-out  appearance  as  it  is  usually  stated.  The 
contents  of  the  intestinal  tract  in  the  upper  part  are  thin,  yellowish 
or  grayish  watery  fluid  containing  particles  of  food  and  little  mucus; 
in  the  colon  the  contents  may  be  the  same  or  may  be  greenish  in  color, 
and  contain  more  flocculi  and  mucus.  Their  odor  is  described  as  musty, 
not  foul.  The  mucous  membrane  of  the  intestine  may  be  cloudy  and 
show  a  slight  loss  of  epithelium  on  the  surface;  the  solitary  follicles  may 


23S 


DISEASES  OF    THE   ALIMENTARY    TRACT 


aj)]H'ar  ;i  littl(>  swollen.  Microscopically,  in  addition  to  this  superficial 
loss,  thcri"  is  some  small  roimd-ccll  infiltration  of  the  mucosa  and 
subnuicosa.  The  intestinal  contents  under  the  microscope  show  particles 
of  food,  a  little  blood,  and  epithelium  in  single  cells  or  in  masses.  The 
lesions  in  other  parts  are  not  important.  The  lunj^s  are  pale  anteriorly, 
posteriorly  con<^ested,  and  with  small  areas  of  collapse.  'J"'he  kidneys  are 
lari^e  and  pale,  with  sll<2;ht  cloudy  defeneration  of  the  epithelium  of  the 
tubules.  The  serous  membranes  arc  dry  and  sticky.  The  blood  is 
rather  thick  and  dark. 

Symptomatology. — The  onset  of  the  disease  is  very  sudden  and  its 
(leveioi)nient  raj)i(l.  An  infant  previously  suffering  from  some  mild 
dioestive  disorder,  or  it  may  be  in  a])j)arcntly  perfect  health,  suddenly 
begins  to  vomit  and  shows  a  rise  of  temperature.  The  vomiting  is  soon 
followed  by  diarrhea.      The  vomitus  is  at  first  the  usual  contents  of  the 

stomach,  later  thin,  watery  fluid 
mixed  with  little  mucus.  The  stools 
likewise  consist  at  first  of  ordinary 
intestinal  contents,  but  rapidly  be- 
come thinner,  green  or  gray  or  almost 
colorless,  very  watery,  and  with  a 
musty  odor.  In  the  severe  cases  the 
vomiting  and  purging  become  almost 
incessant,  the  stomach  will  retain 
nothing,  the  bowels  move  fifteen  or 
twenty  times  in  twenty-four  hours, 
and  the  infant  shows  a  profound 
constitutional  depression.  Substance 
and  weight  are  lost  rapidly,  as  the 
tissues  are  drained  by  the  serous  dis- 
charges from  stomach  an<l  bowels. 
The  surface  is  cold,  especially  the 
extremities,  w'hile  the  rectal  tempera- 
ture mounts  more  or  less  steadily, 
in  the  fatal  cases  reaching  107°  or 
108°  F.  before  death.  The  eyes  are 
sunken,  the  pulse  rapid  and  feeble, 
and  the  respiration  shallow^  and 
weak.  The  children  are  limp  from 
exhaustion  and  nuiscular  relaxation.  Thirst  is  severe  and  distressing. 
The  (|uantity  of  urine  is  greatly  decreased.  The  abdomen  is  usually 
retracted  and  soft.  The  mental  condition  is  profoundly  affected. 
At  first  the  infants  are  restless  and  fretful,  but  soon  pass  into  a  con- 
dition of  partial  stupor,  in  which  they  lie  with  sunken,  up-turned  eyes, 
tossing  the  head  from  side  to  side,  trying  to  moisten  their  dry  lips 
witli  parched  tongues,  and  either  entirely  silent  or  moaning  piteously. 
Wild  deliiium  may  at  times  occur.  Convulsions  are  not  uncommon. 
Temporary  remissions  in  the  vomiting  and  purging  may  occur,  but  in 
the  majority  of  instances  the  downward  progress  is  usually  steady. 


F 

G. 

IL 

DATE 

(i 

; 

S 

HOUR 

r, 

9    I     5 

9         0 

300 
105 

loi 

i  m 

< 

1  10;i 

< 

S  101 

t- 

100 

99' 

/ 

/ 

/ 

/ 

j 

I 

I 

j 

1 

PULSE 

0 

0 

3 

0 

1 

RESP 

s 

r- 

p 

- 

•* 

Temperature  chart  of  a  fatal  ease  of  cholera 
infantum  in  a  child  eight  months  old. 


ACUTE   GASTROEXTERIC   IXFECTIONS  239 

Most  of  the  fatal  cases  terminate  within  forty-eight  or  seventy-two  hours 
(Fig.  42).  Some  writers  speak  of  an  algid  state  with  a  subnormal  temper- 
ature, but  this  I  have  never  seen.  In  other  instances  the  onset  and  course 
of  the  disease  are  not  so  severe.  The  fever  develops,  the  vomiting  and 
purging  have  the  typical  character,  but  are  not  so  continuous,  the 
constitutional  depression  is  not  so  profound,  the  infants  rally,  and,  in  the 
course  of  a  few  days,  the  temperature  falls,  the  emesis  and  diarrhea 
gradually  lessen,  and  the  infants  convalesce  normally.  In  other  instances 
the  infants  rally  partially,  but  gradually  develop  the  symptoms  and 
apparently  also  the  lesions  of  an  acute  ileocolitis,  which  will  be  described 
later. 

Diagnosis. — This  is  usually  easy.  The  frequency  and  character  of  the 
vomiting  and  purging,  takeij  with  the  fever  and  sudden  collapse  occur- 
ring in  an  artificially  fed  child  under  three  years  of  age,  are  sufficient  to 
stamp  the  picture  clearly.  The  only  other  affection  producing  such 
symptoms  is  the  true  Asiatic  cholera,  from  whose  ravages  we  are  happily 
free.  In  conditions  which  warrant  a  doubt  a  bacteriological  examination 
of  the  stools  for  the  specific  organism  would  be  required  to  settle  the 
question.  In  some  cjuarters  the  affection  has  been  confused  with  sun- 
stroke, but  the  much  more  rapid  development  of  coma  in  the  latter 
without  the  characteristic  vomiting  and  purging  easily  distinguish  the 
two.  Some  of  the  less  severe  cases  closely  resemble  the  acute  ileocolitis, 
but  are  distinguLshable  by  the  difference  in  the  vomitus  and  stools,  by 
higher  temperature,  and  more  rapid  recovery  when  once  the  severe 
storm  of  onset  is  passed.  Some,  indeed,  of  the  cases  go  on  to  develop  the 
features  of  an  ileocolitis,  as  already  observed. 

Prognosis. — This  is  by  all  means  the  most  serious  and  fatal  of  the 
acute  diarrheal  diseases  of  infancy.  The  great  majority  of  the  cases  are 
fatal  and  are  apparently  little  influenced  by  treatment.  The  possibility 
of  recovery  seems  to  rest  rather  upon  the  vitality  of  the  patient  and  the 
severity  of  the  poisoning  than  upon  the  treatment  employed.  As  Holt 
observes,  there  is  little  ground  for  the  assurance  that  the  fatal  result 
might  have  been  averted  had  the  physician  been  called  sooner. 

Prophylaxis. — The  essential  points  in  this  regard  have  already  been 
given  above.  The  vital  point  lies  in  the  condition  of  the  milk  given  for 
food.  Pure  milk,  properly  kept,  will  never  produce  cholera  infantum. 
Milk  loaded  with  bacteria,  and  kept  at  temperatures  permitting  bacterial 
growth,  may.  It  is  also  well  to  remember  that  apparently  trivial  digestive 
disorders  may  open  the  way  for  these  acute  distur}3ances  or,  at  least,  make 
the  patient  more  vulnerable. 

Treatment. — There  are  three  chief  indications:  1.  To  empty  and 
cleanse  the  stomach  and  intestine.  2.  To  control  the  temperature.  3. 
To  combat  the  collapse. 

^Medication  by  either  of  the  ordinary  routes  and  feeding  are  for  the 
time  out  of  the  question.  Food  should  be  at  once  stopped.  1.  The 
stomach  and  bowels  are  both  to  be  cleansed  by  washing.  Simple  salt 
solution  or  solution  of  sodium  bicarbonate,  4  gm.  to  500  c.c.  (1 
teaspoonful  to  the  pint)  may  be  used  for  this  purpose.    The  washing  of 


240 


DISEASES  OF   THE   AIJMEXTARY    TRACT 


the  stomach  should  be  done  with  water  at  a  temperature  of  about  100°  F. 
Tlie  bow(>ls  may  l)e  washed  with  water  at  a  temperature  of  00°  F.  If 
the  vomiting  and  purging  eontimie,  these  washings  may  be  repeated  in 
four  to  six  hours,  but  it  is  usually  not  advisable  to  continue  them  so 
frequently  for  more  than  one  day.  2.  The  temperature  is  to  be  con- 
trolled by  baths  or  packs.  The  bath  is  to  be  preferred  because  friction 
can  be  employed  at  the  same  time  to  keep  up  the  circulation  and  prevent 
collapse.  Tlie  infant  is  to  be  put  in  water  at  a  temperature  of  95°  to 
100°  F.  and  then  the  temperature  is  to  be  gradually  lowered  to  85°  F.,sucli 
a  bath  to  be  continued  for  fiftecMi  to  thirtv  minutes.     Constant  friction, 


Fig.  -13 


Method  of  hypodermoclysis.  The  bottle  contaius  normal  salt  solution.  The  tube  is  tirst  filled  by 
"  stripping"  to  start  siphon  action.  Two  needles  are  used,  one  being  inserted  on  either  side  of  the 
abdomen. 

especially  of  the  extremities,  should  be  employed  during  the  bath. 
Where  the  baths  fail  to  control  the  temperature,  rectal  irrigation  with 
ice- water  has  been  recommended,  the  water  being  allowed  to  run  in 
and  out  freely;  but  I  have  seen  collapse  produced  or  aggravated  so  often 
by  such  measures  as  to  consider  them  more  likely  to  be  harmful  than 
good.  The  baths  may  be  repeated  every  two  or  three  hours  as  necessary. 
In  the  intervals  between  the  batlis  cold  packs  to  the  trunk  may  be 
employed,  the  infant  being  wrapped  in  a  sheet  wrung  out  of  water  at  a 
temperature  of  90°  F.  and  water  of  the  same  temperature  sprinkled  over  it 


ACUTE   GASTROENTERIC   INFECTIONS  241 

from  time  to  time.  In  cases  of  marked  depression  it  is  well  to  leave 
the  feet  and  legs  out  of  the  water  and  apply  heat  to  the  feet.  Cold 
applications  are  to  be  employed  on  the  head.  3.  To  meet  the  collapse 
stimulants  are  necessary,  but  cannot  be  given  by  the  mouth  or  rectum ; 
they  must  be  introduced  by  the  skin.  Normal  salt  solution,  3  gm.  to 
500  c.c.  (45  grains  of  salt  to  a  pint  of  sterile  water),  is  to  be  given  by 
hypodermoclysis  (Fig.  43).  The  ordinary  siphon  apparatus  suffices  for 
this  purpose.  The  apparatus  must  be  sterile.  200  to  300  c.c.  can  in  this 
way  be  given  at  one  time.  Hypodermoclysis  has  the  great  advantage 
that  it  not  only  acts  as  a  stimulant,  but  supplies  the  fluid  which  is 
so  greatly  needed  in  the  tissues  and  to  promote  the  excretions  of 
poisons  by  the  urine.  The  injection  may  be  repeated  at  discretion  in 
from  four  to  six  hours.  Fluid  is  taken  up  from  the  loose  cellular 
tissue  with  great  rapidity  under  these  circumstances.  Holt  espe- 
cially recommends  the  injection  of  morphine,  0.0006  gm.  (gr.  y^o^), 
and  atropine,  0.000075  gm.  (gr.  -g-^Tf),  as  stimulants  to  the  heart,  and 
especially  for  the  relief  of  severe  nervous  symptoms.  Cardiac  stimulants, 
whiskey,  camphor,  ether,  may  be  given  hypodermically  also.  Whiskey 
in  0.30  to  0.60  c.c.  (5  to  10  minim)  doses  is  to  be  given  well  diluted  with 
hot  water;  ether  may  be  used  pure  in  like  quantities.  Camphor  is  to  be 
dissolved  in  a  sterile  sweet-almond  oil,  1  part  to  10,  and  from  0.30  to  0.60 
c.c.  (5  to  10  minims)  given  at  a  time. 

If  with  these  various  remedies  we  check  the  onward  progress  of  the 
disease  the  vomiting  and  purging  lessen  and  the  nervous  symptoms 
improve.  So  soon  as  the  stomach  permits  we  may  begin  the  admin- 
istration of  iced  champagne  or  brandy  well  diluted,  5  to  10  drops  in 
a  teaspoonful  by  mouth.  As  the  tolerance  of  the  stomach  increases, 
ice-water  may  be  given  by  mouth  in  increasing  quantities.  The  more 
fluid  that  can  be  gotten  into  the  system  the  better,  but  the  return  of 
vomiting  will  frequently  check  these  measures.  After  twenty-four 
hours'  improvement  we  may  begin  feeding  with  liquid  peptonoids  or 
panopepton,  2  to  4  c.c.  (h  drachm  to  1  drachm)  in  water  given  every 
two  or  three  hours.  If  this  is  well  borne  we  may  after  twelve  or 
twenty-four  hours  give  whey,  beginning  with  15  c.c.  to  30  c.c.  (^  ounce 
or  1  ounce),  once  in  two  hours,  and  gradually  increasing  the  quantity. 
From  this  transition  may  be  made  to  milk  diluted  as  in  acute  gastric 
disturbances,  and  then  we  may  gradually  work  back  to  ordinary  feed- 
ing. If  the  diarrhea  persists  with  the  presence  of  mucus  or  mucus  and 
blood  in  the  stools  the  cases  must  be  treated  as  ileocolitis. 


16 


CHAPTER    XII. 

THE  DIARRHEAS  OF  INFANCY  AND  CHILDHOOD— DISEASES  OF 
THE  INTESTINES. 

THE  DIARRHEAS  OF  INFANCY  AND  CHILDHOOD. 

The  most  important  of  the  illnesses  of  infancy  and  cliiltlliood  are  the 
disorders  of  the  intestinal  tract  associated  with  diarrhea.  The  great 
part  of  the  mortality  of  infancy  is  due  to  these  diarrheal  (lisea,ses,  and 
many  children  who  arc  not  killed  by  them  are  left  permanently  impaired 
in  stature  and  vigor  and  may  suffer  from  digestive  disorders  for  the 
remainder  of  life.  In  considering  the  cause  of  such  disorders  many 
factors  must  be  admitted. 

1.  Physiological. — Relatively  the  alimentarv  tract  of  an  infant  is 
called  upon  for  vastly  more  work  than  that  of  the  adult.  A  healthy 
infant  at  the  age  of  a  year  will  take  and  digest  from  one  quart  to  a  (juart 
and  a  half  of  cows'  milk.  An  adult  we  find  can  be  sustained  by  from 
two  to  four  quarts.  The  weights  of  the  two  are  to  one  another  as  1  to  7 
or  1  to  8.  The  infant  for  his  weight  is  doing  three  or  four  times  the 
digestive  work  of  the  adult.  This  greater  activity  of  the  digestive 
apparatus  entails  a  greater  sensibility  to  disturbing  influences,  so  that 
the  slightest  change  in  diet  or  regime  may  in  infancy  be  reflected  in 
some  intestinal  disorder. 

2.  Mode  of  Feeding. — Breast-fed  infants  suffer  much  less  from 
diarrheal  diseases  than  those  artificially  fed.  As  a  rule  not  more  than 
2  per  cent,  or  3  per  cent,  of  the  chiklren  suffering  from  summer  diarrheas 
are  breast-fed.  It  is  not  merely  the  differences  in  chemical  composition 
of  cows'  milk  and  human  milk  that  come  here  into  play,  for  the  cleanli- 
ness of  the  milk,  its  freshness,  the  care  with  which  it  is  prepared  and 
given,  all  serve  to  influence  the  result.  It  is  generally  recognized  that 
since  the  poorer  classes  of  the  people  have  learned  the  advantages  of 
sterilization  of  milk,  the  frequency  of  diarrheal  diseases  has  steadily 
diminished. 

In  older  children  the  eating  of  green  fruit  and  unrestrained  indulgence 
in  candies,  ice-cream,  and  soda-water  serve  to  bring  on  these  affections. 

3.  Age. — The  period  from  the  sixth  to  the  eighteenth  month  is  the 
period  of  life  most  afflicted  by  diarrheal  diseases.  This  corresponds  with 
the  time  of  substitution  of  artificial  feeding  for  the  breast,  or  among  the 
poorer  classes  the  substitution  of  table  feeding  for  the  bottle.  It  is  no 
uncommon  thing  among  the  poor  to  find  children  not  yet  a  year  old 
getting  practically  the  food  and  drink  of  their  parents,  even  to  beer  and 
berries  in  the  summer  season. 

(242) 


DISEASES  OF  IXTESTIXES  IX   IXFAXCY   AXD   CHILDHOOD     243 

4.  Season. — The  diarrheal  diseases  prevail  to  a  greater  or  less  extent 
all  the  year  round,  and  the  summer  is  the  time  of  special  danger.  The 
wave  of  mortality  from  infantile  diarrheas  begins  in  June,  earlv  or  late, 
depending  upon  the  atmospheric  conditions,  rises  to  a  maximum  in  July 
or  August,  and  continues  with  little  change  until  the  cooler  days  of 
September  bring  relief.  The  mortality  also  varies  from  year  to'vear 
directly  with  the  severity  of  the  summer  heat.  The  two  summers  of 
1902  and  1903  in  Xew  York  City  were  notably  mild,  and  the  ravao-es  of 
the  diarrheal  diseases  were  correspondingly  less. 

5.  Surroundings. — The  tenement  districts  of  our  great  cities  suffer 
most  severely  from  these  affections,  but  they  are  not  unknown  in  the 
country.  The  cliildren  of  the  well-to-do  escape,  for  the  most  part, 
because  they  have  the  advantages  of  pure  air,  sunlight,  etc.,  combined 
with  due  care  in  the  selection,  preparation,  and  giving  of  their  food. 
The  children  of  the  poor  suffer  not  only  because  they  have  not  pure 
air  and  are  surrounded  oftentimes  by  filth,  but  still  more  bv  reason  of 
their  being  fed  on  impure  milk,  which  is  prepared  without  care,  and 
given  in  the  way  that  involves  the  least  trouble.  The  establishment  of 
depots  for  the  distribution  of  sterilized  milk  in  our  large  cities  has  done 
much  to  lower  the  mortality  among  infants  from  these  causes.  In  New 
York  City  the  Strauss  laboratories  and  the  work  of  St.  John's  Guild 
have  been  of  great  value  not  only  for  their  direct  help  in  this  way,  but  for 
their  educational  influence  upon  the  poorer  classes  of  the  population. 
The  emphasis  that  is  being  laid  upon  the  necessity  of  watching  the  milk 
supply  of  our  cities,  not  only  that  the  milk  be  up  to  the  standard  in 
composition,  but,  much  more,  that  it  be  clean,  free  from  serious  bacterial 
contamination,  and  that  it  be  supplied  to  the  consumer  with  as  little 
delay  as  possible  after  milking,  is  exerting  an  influence  all  over  the 
cotmtry,  until  even  now  in  the  smaller  cities  or  towns  one  will  find 
dairv'men  awake  to  the  new  demand  for  clean  milk  and  endeavoring 
to  supply  it.  '\Mien  our  tenement  population  can  obtain  clean  milk  for 
their  children  they  will  suffer  less  from  diarrheal  diseases. 

6.  Care  of  Children. — Tliis  is  certainly  a  factor  of  great  importance. 
It  has  not  been  clearly  sho'^m  that  the  summer  diarrheas  are  trans- 
missible, but  there  is  little  doubt  that  they  are.  The  demonstration  of 
the  presence  of  a  specific  agent  such  as  the  Shiga  bacillus  in  a  large 
proportion  of  these  diarrheas  certainly  implies  that  the  affection  may 
be  directly  transmitted  from  one  to  the  other.  The  prompt  change  of 
soiled  diapers  is  to  be  enjoined,  lest  the  child  contaminate  its  hands  and 
so  reinfect  itself  or  convey  infection  to  others.  Thorough  cleanliness  of 
the  child's  person  should  be  enforced,  and  nurses  or  others  handling 
these  children  should  be  cautioned  as  to  the  cleansing  of  their  hands. 
Especially  should  anyone  feeding  an  infant  be  careftil  of  the  cleanliness 
of  the  hands,  so  as  not  to  contaminate  the  bottle  or  nipple,  and  thus 
infect  a  child.  These  precautions  are  particularly  necessary"  in  all  large 
institutions  or  hospitals  where  numbers  of  children  suffering  from  these 
diarrheal  diseases  are  gathered  together. 

We  cannot  teach  infants  not  to  put  their  fingers  in  their  mouths,  and 


244  DISEASES  OF  THE  ALIMENTARY    TRACT 

unless  their  hands  are  kept  clean,  we  cannot  prevent  their  taking  in 
bacteria  that  may  do  harm.  It  has  been  shown  that  tubercle  bacilli 
can  be  carried  under  the  nails  in  the  dirt  gathered  from  the  floors  of 
dwellings  or  the  streets. 

INIost  of  all,  the  pernicious  custom  of  giving  infants  "comforts"  and 
such  like  objects  to  suck  should  be  warred  upon.  When  we  see  mothers 
picking  these  objects  from  the  floor,  the  carriage,  or  even  the  street,  and 
with  a  hasty  brush  of  the  hand  restoring  them  to  their  children's  mouths, 
we  wonder  how  so  many  of  the  children  survive  the  experience. 

7.  Constitutional  Condition. — diildren  that  are  weakly  from  any 
cause,  but  especially  those  suU'ering  from  rickets,  syphilis,  or  tuberculosis, 
or  nuilnutrition  in  any  form,  are  subject  to  these  diarrheal  diseases. 
For  this  reason  children  in  hospitals  or  asylums  are  especially  prone  to 
these  affections,  and  great  numbers  of  them  are  carried  ofl"  yearly  by 
them.  Even  the  slightest  disorder  of  the  gastroenteric  tract  in  an  infant 
or  child  is  of  importance,  for  the  reason  that  during  the  summer  it  is 
very  likely  to  become  so  much  worse  as  to  seriously  affect,  if  not  destroy, 
the  individual's  life.  It  is  this  fact  which  renders  important  the  careful 
treatment  of  even  the  slightest  gastroenteric  disorder  in  the  early  years, 
a  fact  that  also  serves  to  explain  the  greater  seriousness  of  these  dis- 
orders among  the  poor,  who  regularly  wait  until  the  disorder  has  assumed 
a  serious  character  before  seeking  advice  or  instituting  proper  treatment. 

S.  Bacteria. — Although  investigation  has  shown  that  there  were 
myriads  of  bacteria  present  in  the  intestine  in  these  diarrheal  disorders, 
it  was  not  until  recently  that  any  specific  relation  could  be  established 
between  any  of  these  bacteria  and  the  diseases  in  question.  It  now 
seems  established  that  a  bacillus  of  the  colon-typhoid  group,  known  as 
the  Shiga  l)acillus,  from  the  original  discoverer,  can  be  regarded  as  the 
specific  agent  in  a  considerable  number  and  variety  of  these  diarrheas. 
Just  how  large  a  part  of  our  summer  epidemics  will  be  accounted  for 
in  this  way  it  is  too  early  to  say,  but  observations  made  during  the  past 
two  summers  indicate  that  this  bacillus  is  to  be  found  in  practically  all 
the  summer  diarrheas  in  which  mucus  and  blood  are  found  in  the  stools, 
and  in  a  certain  proportion  of  the  cases  in  which  these  constituents  are 
absent.  Of  the  life-history  of  this  organism  outside  the  body  very  little 
is  yet  known.  The  natural  assumption  is  that  infection  takes  place  by 
means  of  water,  milk,  etc.,  but  of  this  there  has,  as  yet,  been  no  scientific 
demonstration.  How  far  the  hopes  that  these  discoveries  will  in  the 
end  reveal  the  modes  of  infection,  determine  the  means  of  prevention, 
and  possibly  materially  reduce  the  mortality  from  the  diarrheal  affec- 
tions of  summer  are  to  be  realized  is  altogether  uncertain  at  present. 
(See  page  227.) 

The  relation  of  the  bacteria  in  milk  to  these  disorders  is  an  interesting 
question.  It  is  well  known  that  1  c.c.  of  milk,  as  it  comes  to  the  con- 
sumer, contains  from  5000  to  5,000,000  or  even  10,000,000  bacteria. 
Of  just  what  varieties  this  enormous  total  is  made  up  but  little  is  known, 
except  that  nearly  all  are  non-pathogenic  to  man.  The  tubercle  bacillus 
is  the  only  pathogenic  organism  found  at  all  frequently  in  milk.    Diph- 


DISEASES  OF  IXTESTIXES  IX  IXFANCY  AXD   CHILDHOOD     245 

theria  and  typhoid  bacilli  have  been  found  in  a  very  few  instances. 
Streptococci  are  practically  always  present,  but  it  is  not  known  that  the 
varieties  of  streptococcus  found  have  any  harmful  effect  upon  the  human 
organism.  Although  it  has  not  yet  been  shown  in  just  what  way  these 
multitudes  of  bacteria  in  milk  affect  the  individual  consuming  it,  it  has 
been  clearly  shown  that  a  high  bacterial  content  is  associated  with 
conditions  in  the  milk  that  render  it  harmful,  that  produce  gastroenteric 
disorders,  and  is  therefore  sufficient  ground  for  the  rejection  of  such 
milk  as  food,  particularly  in  the  cases  of  invalids  or  children. 


SIMPLE  DIARRHEAS. 

By  this  term  we  designate  the  diarrheas  which  are  marked  bv  the 
frequent  movements  of  the  bowels,  the  stools  consisting  only  of  undigested 
food  or  food  and  water,  without  blood  or  mucus,  and  unaccompanied 
by  fever  or  severe  constitutional  disturbance.  A  number  of  varieties 
are  distinguished, 

1.  Mechanical. — Undigested  food  of  any  kind,  such  as  fruits,  nuts, 
green  corn,  and  the  like,  may  produce  diarrhea,  simply  by  acting  as 
mechanical  irritants,  stimulating  peristalsis  and  driving  the  intestinal 
contents  through  before  digestion  is  completed.  The  movements  in 
these  cases  are  frequent  and  watery,  and  contain  more  or  less  undigested 
food,  often  plainly  showing  its  original  structure,  A  dose  of  castor  oil 
or  calomel,  with  some  restriction  of  diet  for  a  time,  promptly  cures 
these  cases. 

2.  Nervous  or  Reflex  Diarrhea. — That  nervous  excitement  or 
emotion  can  produce  a  diarrhea  is  a  fact  known  to  all,  and  applies  to 
children  as  well  as  to  adults.  The  influence  produced  by  dentition  upon 
the  intestines  has  been  somewhat  del^ated.  There  seems  to  be  no 
question  that  the  eruption  of  a  tooth  can  produce  a  diarrhea  which  will 
last  until  the  tooth  is  through  the  gum  and  then  subside.  Admitting  this, 
one  need  not  agree  to  the  common  belief  that  all  the  diarrheas  of  the 
period  of  dentition  or  of  infancy  are  due  to  teething  and  should  be 
permitted  to  run  their  course,  because  stopping  the  diarrhea  would 
injure  the  child.  A  sudden  chill  or  wetting  of  the  feet  may  also  excite  a 
simple  diarrhea  which  belongs  in  this  class.  The  management  of  these 
reflex  diarrheas  consists  simply  in  the  treatment  of  the  cause  of  irritation 
— as  soon  as  that  is  removed  the  diarrhea  ceases. 

3.  Colliquative  Diarrhea. — Colliquative  diarrhea  is  seen  in  certain 
of  the  infectious  diseases,  or  in  uremia.  The  diarrhea  in  these  cases 
seems  simply  to  be  one  of  nature's  methods  of  getting  rid  of  poisons,  just 
as  we  ourselves  are  accustomed  to  move  the  bowels  freely  in  the  effort 
to  free  the  system  from  toxins.  To  a  certain  extent,  therefore,  these 
disorders  are  protective  and  not  harmful,  but  they  often  run  on  to  an 
extent  that  saps  the  patient's  strength  and  greatly  reduces  him.  It  is 
then  necessary  to  stop  them.  A  severe  diarrhea  in  the  course  of  a 
pneumonia,  for  example,  is  always  a  grave  symptom  and  seems  often 


246  DISEASES   OF   THE   ALIMEXTARY    TRACT 

to  determine  a  fatal  outcome.  Whether  this  is  .simj)ly  another  evidence 
that  in  .such  cases  the  system  is  overcharged  with  to.xins  and  the  indi- 
vidual is  too  poisoned  to  recover,  or  the  diarrhea  itself  exhausts  the 
patient,  it  is  difficult  to  say.  To  check  such  a  collicjuative  diarrhea 
we  would  change  the  nourishment  to  a  simj)ler  and  more  digestihle  form, 
such  as  pej)tonize(l  and  sterile  milk,  or  withdraw  milk  entirely  and  u.se 
only  i)eef-juice,  barley-water,  or  whey,  and  give  sufficient  doses  of  opium 
to  check  the  motions.  The  opium  is  best  given  in  the  form  of  Dover's 
powder,  0.00 12o  to  0.00  gm.  (gr.  y  to  gr.  1),  which  may  be  given  every 
two  or  three  hours  to  a  child  under  two  years,  until  the  desired  (>ffect 
is  pnxJuced.  Paregoric  may  be  used  instead,  the  dose  for  an  infant  a 
year  old  i)eing  from  0.00  to  1  c.c.  (10  to  15  minims). 

4.  Diarrhea  from  Drugs. — Diarrhea  may,  of  course,  be  excited  by 
the  use  of  drugs.  There  is  certainly  some  ground  for  the  belief  that  in 
nurslings  diarrhea  may  be  excited  by  the  presence  in  breiist  milk  of 
purgative  drugs  which  the  mother  has  taken. 


ACUTE  INTESTINAL   INDIGESTION. 

This  affection  is  analogous  to  the  acute  gastric  indigestion  already 
described,  both  in  etiology,  lesion,  course,  and  treatment.  It  may  or 
may  not  be  accompanied  by  gastric  symptoms,  l)ut  in  this  case  the 
intestinal  disturbance  is  the  chief  factor  and  dominates  the  clinical 
picture. 

Etiology. — As  in  the  gastric  affection,  the  cause  is  nearly  always  some 
irregularity  in  feeding,  such  as  the  taking  of  too  much  food,  or  of  indi- 
gestible food,  food  of  bad  quality,  sudden  changes  in  the  dietary,  etc. 
In  brea-st-fed  infants  we  find  acute  intestinal  indigestion  occurring  in 
the  infant  in  connection  with  disturbances  in  the  mother's  health, 
sometimes  in  relation  to  the  menstrual  period,  in  other  cases  attending 
unusual  excitement  or  exertion  on  the  mother's  part.  It  may  be  that 
analysis  of  the  breast  milk  in  these  cases  will  show  some  distinct 
changes  in  its  composition,  but  often  this  is  not  the  case.  Not  infre- 
quently as  the  breast  milk  begins  to  fail,  it  becomes  poor  in  fat,  over-rich 
in  proteids,  and  then  excites  an  acute  intestinal  indigestion  in  the  infant. 

in  artificially  fed  children  this  disturbance  may  be  brought  about  by 
faulty  composition  of  the  milk,  attempts  to  feed  too  large  ])roportions 
of  proteids,  sometimes  apparently  also  by  too  low  proteids,  by  feeding 
milk  that  is  laden  with  Ijacteria,  or  that  has  become  changed  by  them. 
The  early  feeding  of  solid  food,  especially  if  that  solid  food  be  of  an  indi- 
gestible character,  is  a  common  cause  in  infants  who  are  being  weaned. 
The  farinaceous  foods  l)y  reason  of  the  readiness  with  which  they  undergo 
decomposition  are  particularly  likely  to  set  up  such  a  disturbance. 

Exposure  to  wet  or  cold  with  resulting  chilling  of  the  surface  and 
congestion  of  the  internal  organs  is  a  factor  of  some  importance.  As  is 
well  known  also  the  heat  of  summer  so  affects  the  digestive  apparatus 
that  during  the  summer  an  infant  may  no  longer  be  able  to  digest  a  f<xxl 


DISEASES  OF  INTESTINES  IN  INFANCY  AND  CHILDHOOD     247 

which  he  had  previously  been  taking  care  of  perfectly  well,  and  the  first 
evidence  of  this  may  be  an  attack  of  acute  intestinal  indigestion.  Children 
of  either  sex  and  of  any  age  are  susceptible,  but  the  greater  proportion 
of  cases  occurs  in  those  from  six  to  eighteen  months  of  age.  It  has 
already  been  pointed  out  that  children  whose  vitality  has  been  lowered 
by  reason  of  any  constitutional  disease — rickets,  syphilis,  tuberculosis,  or 
malnutrition  of  any  form — are  more  susceptible  than  others  to  these 
digestive  disorders. 

Pathology. — We  infer  that  in  these  cases  there  is  a  functional  disturb- 
ance of  the  intestine  without  definite  anatomical  lesion,  but  the  border- 
line between  this  and  catarrhal  inflammation  is  purely  theoretical. 
Many  writers  in  fact  include  acute  catarrhal  inflammation  of  the  intes- 
tines under  this  heading. 

Symptomatology. — The  attack  of  acute  intestinal  indigestion  is  either 
sudden  in  onset  or  the  symptoms  develop  gradually.     In  acute  cases  the 


Fig. 

44 

DATE 

21 

22 

23 

24 

25 

26 

2T 

28 

103" 

102° 

?  101° 

< 

5    100° 

t- 
< 

1      99° 

98° 

S 

\, 

s 

\ 

K 

\ 

^ 

j 

1 

1 

1 

y 

y 

I 

y 

^ 

-- 

/ 

\ 

y 

. 

^ 

^ 

\ 

y 

^ 

' 

/ 

' 

"^ 

/ 

/ 

/ 

97 

PULSE 

140 

130 

134 

134 

128 

130 

128 

ii(i 

RESP. 

38 

40 

30 

30 

28 

2C 

24 

20 

Temperature  chart  of  a  case  of  intestinal  indigestion  in  a  ciiild  eight  months  old. 

onset  is  marked  by  a  sudden  rise  of  temperature,  102°  to  104°  F.  (Fig.  44), 
abdominal  pain,  restlessness,  peevishness,  disturbed  sleep,  rapid  pulse, 
and  more  or  less  languor.  In  feeble  children  even  convulsions  may  occur. 
The  diarrhea  may  not  appear  until  some  hours  after  the  onset  of  the 
attack.  When  it  does  occur  the  movements  contain  the  undigested 
food  (not  infrequently  the  cause  of  the  disturbance  can  be  detected  in 
the  stools)  and  are  very  watery.  In  these  severe  cases  there  is  usually 
some  vomiting  at  the  outset,  but  this  quickly  subsides.  After  the  first  day 
or  two  the  temperature  falls  and  the  pulse  becomes  slower,  but  the  diarrhea 
persists  (Fig.  45).  Usually  the  appetite  is  lost  and  the  tongue  coated 
white,  but  on  account  of  the  loss  of  water  in  the  stools  thirst  is  marked. 
The  abdomen  may  be  distended  and  tympanitic,  but  frequently  remains 
flat.     The  urine  is  scanty  and  high  colored.     The  child  usually  shows 


248 


DISEASES  OF   THE  ALIMEXTARY   TRACT 


marked  prostration,  the  eyes  are  sunken,  the  face  is  paUid,  weight  is 
lost  very  rapidly,  particularly  in  children  previously  fat,  and  there  is  a 
general  muscular  relaxation. 

In  the  less  acute  ca^es  the  onset  may  be  without  temperature,  marked 
onlv  by  restlessness,  fretfulness,  and  crying  from  the  abdominal  pain; 
the  diarrhea  is  not  so  severe  and  vomiting  is  less  likely  to  occur.  After 
the  first  day  or  two  the  course  of  the  affection  is  much  the  same.  The 
loose  movements  are  most  likely  to  follow  feeding,  each  bottle  or  nursing 
being  followed  by  one  or  two  loose  dejections.  The  character  of  the 
movements  is  characteristic.  At  first  they  are  yellow  with  more  or 
less  undigested  food.     If  the  food  is  milk,  the  casein  appears  in  Hakes 


Fig.  45 


DATE 

*> 

8 

HOUR 

S     1     o 

9    1    5 

9    1    5 

9    1    5 

9    15 

IOC 

104 
I  Wi 

t  10-i 

5 
^  lof 

loo' 

90° 

__L_:   L 

1 

1 

\ 

1 

\ 

, 

1 

1 

1 

I 

1 

\ 

1 

- 

1 

1 

1 

- 

A  1 

^ 

^ 

L/  a; 

A 

' — 

j 

\/ 

1 

r 

FULSE 

140 

l-,'7 

l-JO 

IIG 

114 

RESP. 

34 

as 

34 

as 

•iK, 

Temperature  chart  of  a  case  of  intestinal  indigestion  in  a  child  aged  ten  months. 


in  the  watery  fluid,  or  in  large,  rough,  white  masses  mingled  with  the 
vellow  of  normal  feces.  Soon  the  color  changes  to  a  green,  in  which  the 
white  masses  of  casein  are  conspicuous,  or  the  whole  stool  becomes  of 
a  bright  grass-green  hue.  The  change  in  color,  it  has  been  shown,  has 
been  caused  by  the  substitution  of  biliverdin  for  the  bilirubin  of  normal 
feces,  but  the  exact  explanation  of  this  substitution  is  not  known. 

The  duration  of  an  attack  of  acute  intestinal  indigestion  varies  from 
one  or  two  days  to  a  week.  Usually  the  diarrhea  gradually  subsides 
and  the  other  disturbances  with  it.  Repeated  attacks  may  lead  to  more 
serious  intestinal  disturbance,  such  as  the  ileocolitis  to  be  described  later, 
or  a  chronic  intestinal  indigestion. 

Diagnosis. — The  course  of  the  affection  is  characteristic.  The  char- 
acter of   the  diarrhea  taken  with    the  other  symptoms  and    the  rapid 


DISEASES  OF  INTESTINES  IN  INFANCY  AND  CHILDHOOD     249 

subsidence  of  the  disturbance  distinguish  it  from  the  more  serious 
disorders  of  the  intestinal  tract.  Until  the  diarrhea  appears  there  is 
nothing  to  warrant  a  diagnosis. 

Prognosis. — The  attack  is  rarely  fatal  except  in  an  infant  already 
greatly  enfeebled,  but  it  is  remarkable  how  rapidly  an  apparently 
healthy  child,  especially  the  large,  fat,  rosy  baby,  will  fail  under  such 
an  attack.  It  loses  weight  and  is  prostrated  to  an  extent  that  it  may  , 
require  weelcs  to  repair.  This  applies  particularly  to  babies  who  are 
fed  artificially  on  patent  foods.  If  proper  care  is  not  taken  one  attack 
may  open  the  way  for  a  severe  intestinal  infection,  or  the  persistence  of 
the  cause  may  lead  to  a  chronic  disorder. 

Prophylaxis. — In  this  is  involved  the  proper  regulation  of  the  diet 
and  life  of  a  child,  especially  during  infancy,  and  although  a  thorough 
consideration  of  the  subject  cannot  be  given  here,  there  are  two  points 
which  can  properly  be  made:  1.  That  during  the  summer  months  the 
feeding  of  a  child  should  be  kept  relatively  low  both  in  quantity  and  in 
proportions.  Especially  is  this  necessary  under  the  conditions  which  pre- 
vail in  cities  like  New  York,  where  many  of  the  children  are  sent  to  the 
country  for  the  summer,  and  are  thus  deprived  of  the  careful  supervision 
which  they  enjoy  the  rest  of  the  year.  It  is  my  custom  to  stop  increases 
in  the  feeding  about  the  first  of  June,  and  let  the  children  pass  the  sum- 
mer on  the  food  which  they  have  shown  ability  to  digest  up  to  that  time. 
Even  this  may  not  be  sufficient  and  further  dilution  may  be  required. 
If  increases  are  made  either  in  quantity  or  quality,  they  should  be  care- 
fully watched.  2.  INIany  physicians  have  given  up  the  custom  of 
pasteurizing  or  sterilizing  the  milk  used  in  infant  feeding,  especially 
now  that  in  most  cities  it  is  possible  to  obtain  a  guaranteed  or  certified 
milk  of  very  low  bacterial  content.  While  this  may  be  a  wise  policy 
during  the  winter  months  it  is  not  safe  during  the  summer,  no  matter 
what  guarantee  goes  with  the  milk,  and  all  infant  food  should  be  pasteur- 
ized or  sterilized  from  the  first  of  June  until  the  first  of  October  in  the 
latitude  of  New  York. 

Treatment. — The  first  step  in  active  treatment  is  to  withdraw  the  food 
which  the  infant  has  been  having  for  twenty-four  hours.  Next  give 
a  purgative  that  will  thoroughly  clear  the  intestinal  tract.  It  may  be 
that  this  has  been  already  accomplished  by  the  natural  process,  for 
the  diarrhea  in  these  cases  may  be  regarded  as  an  attempt  to  get  rid 
of  the  offending  material.  If  the  stomach  is  not  disturbed  1  or  2  tea- 
spoonfuls  of  castor  oil  will  serve  the  purpose.  If  there  has  been  vomiting 
it  is  safer  to  use  calomel,  giving  from  0.006  to  0.0125  gm.  (^^  to  ^  grain) 
every  half-hour  or  hour  until  the  bowels  are  freely  purged.  It  is  a  good 
plan  to  follow  the  calomel  in  a  few  hours  or  on  the  following  morning 
by  a  saline,  as  1  or  2  teaspoonfuls  of  a  saturated  solution  of  magnesium 
sulphate  given  in  water. 

Water  is  to  be  given  freely  at  all  times  to  relieve  the  thirst.  After 
twenty-four  hours'  fasting  feeding  is  to  be  resumed  with  extreme  caution. 
In  the  case  of  a  breast-fed  infant,  nursing  may  be  permitted  for  five 
minutes  at  intervals  of  four  to  six  hours  at  first.     The  duration  of  the 


250  DISEASES  OF  THE  ALIMENTARY  TRACT 

nursing  and  its  fret jucnov  may  tlien  l)e  increased  according  to  indications. 
If  return  to  the  breast  milk  aggravates  the  diarrhea  it  will  be  advisable 
to  feed  the  infant  with  whey  or  barley-water  for  another  twenty-four 
hours  before  trying  it  again,  and  in  case  it  seems  then  to  prove  irritating 
it  mav  be  necessary  to  give  up  that  breast  milk  entirely  and  get  a  wet- 
nurse  or  resort  to  artificial  feeding. 

With  a  bottle-fed  infant  feeding  may  be  resumed  by  giving  whey  or 
barlev-water  in  cjuantitiesmuch  less  than  the  infant  has  been  accustomed 
to  and  at  longer  intervals.  After  twenty-four  hours  of  such  feeding 
milk  mav  be  given  again,  beginning  with  a  small  (juautity  added  to  the 
barley-water  or  whey,  half  an  ounce  of  milk  in  three  or  four  ounces 
of  barley-water  or  whey,  and  gradually  increasing  the  quantity  of  milk 
and  redticing  the  diluent,  until  at  the  end  of  a  week  the  infant  is  getting 
the  (juantitv  of  milk  or  milk  and  cream  to  which  it  has  been  accustomed. 
Increases  should  not  be  matle  rapidly,  and  if  at  any  time  the  diarrhea 
increases  or  the  stools  show  more  undigested  food,  the  (juantity  of  milk 
should  be  reduced  again. 

Some  prefer  to  use  milk  alone  in  the  feeding,  beginning  by  using  milk 
diluted  with  9  parts  of  a  4  or  o  per  cent,  solution  of  milk-sugar,  which 
would  give  a  milk  mixture  of  0.4  fat,  4.5-5.5  sugar,  and  0.4  proteid. 
Using  7  parts  of  the  sugar  solution  would  give  a  mixture  of  0.5  fat,  5.5 
sugar,  and  0.5  proteid.  Using  5  parts  sugar  solution,  a  mixture  of  0.6 
fat,  5.6  sugar,  and  0.6  proteid.  Using  3  parts  of  the  sugar  solution,  the 
mixture  would  contain  1  fat,  6  sugar,  and  1  proteid,  etc.  After 
reaching  this  point  in  progress,  one  may  well  use  an  8  per  cent,  cream 
instead  of  the  milk,  and  thus  double  the  percentage  of  fat.  As  a  rule, 
infants  can  take  twice  the  percentage  of  fat  that  they  can  of  proteid, 
and  the  rule  holds  in  these  cases.  In  some  instances  it  may  be  necessary 
to  keep  the  fat  percentage  low  for  some  time.  The  stools  should  be 
carefully  watched  throughout.  The  color  and  consistency  should  gradu- 
ally return  to  normal.  The  white  lumps  or  masses  of  casein  may  be  seen 
for  some  days  in  a  milk-fed  child,  but  they  should  steadily  lessen  in 
number  and  size,  and  the  stools  become  more  smooth.  If  the  fat  is  not 
digested,  it,  too,  may  appear  in  the  stools  in  masses,  which  are  rather 
vellow  in  color,  softer  than  the  curds,  and  dissolve  quickly  in  alcohol 
or  ether. 

The  medicinal  treatment  of  these  cases  amounts  to  very  little.  If 
there  is  much  pain  or  the  movements  are  very  fre(|uent,  opium  may  be 
given — Dover's  powder,  0.015  gm.  (gr.  \),  or  paregoric,  0.60  to  1  c.c. 
(ir[  x-xv),  for  a  one-year-old  child.  It  is  best  to  order  the  sedative 
given  after  each  movement  of  the  bowels,  so  that  if  the  diarrhea  is 
checked  the  medication  will  be  discontinued.  I'he  opium  should  never 
be  given  until  the  alimentary  tract  has  been  thoroughly  cleared  out. 
Whatever  opium  is  given  should  be  administered  by  itself,  and  not  in  a 
complex  prescription,  so  that  the  quantity  of  it  may  be  strictly  regulated 
and  its  administration  promptly  stopped  when  it  is  no  longer  necessary. 

Bismuth  is  commonly  prescribed  in  these  cases  and  seems  to  be  of 
advantage.     It  must  be  given  in  relatively  large  doses,  0.650  gm.  (10 


DISEASES   OF  IXTESTIXES  IX  IXFAXCY   AXD   CHILDHOOD     251 

grains j  or  more  every  t\^'o  hours.  It  may  be  given  in  powders,  each 
powder  being  put  in  a  teaspoonful  of  water  or  of  food.  As  bismuth  is 
insoluble  and  very  hea\w,  it  is  more  convenient  to  administer  it  in 
suspension,  as  in  the  following  prescription: 

^ — Bismuth,  subnitratis 8.0  gm.  (5ij). 

Mucilag.  acacia 8.0  c.c.  (5ij). 

Mist.  Crete q.  s.  ad  125.0    "  (oiv).— M. 

Sig. — i  c.c.  (one  teaspoonful)  every  two  hours. 

As  the  bismuth  is  insoluble  it  may  be  administered  freely  to  infants  of 
any  age. 

The  ireneral  livgiene  of  the  child  should  be  regulated.  Ug-ht  and 
air  should  be  assured.  In  the  sinnmer  the  infant  or  child  should  be  in 
the  open  air  as  much  as  possible.  Often  a  change  from  the  city  to  the 
country  will  marvellously  help  these  cases.  In  New  York,  for  example, 
it  is  found  that  a  single  day  on  one  of  the  Floating  Hospitals  of  St. 
John's  Guild,  which  take  sick  children  from  the  tenement  districts  down 
the  bay,  will  have  a  most  decided  effect  in  restoring  these  patients.  Care 
should  always  be  taken  to  have  the  diapers  promptly  changed,  when 
wet  or  soiled ;  otherwise  the  buttocks  become  reddened  and  excoriated. 

In  older  children  the  same  general  plan  is  to  be  followed.  After 
clearing  out  the  bowels  and  fasting  for  twentv-four  hours,  milk  and 
Vichy  water  may  be  given  in  ecjual  parts.  If  milk  is  not  well  borne, 
broths  may  be  used  instead.  The  strength  of  the  milk  allowed  is  to  be 
gradually  increased.  Opium  may  be  given  on  the  same  indications  as 
above,  and  bismuth  in  large  doses  is  useful. 

In  every  instance  the  effort  should  be  made  to  discover  the  cause  of 
the  disturbance  and  correct  it,  that  there  may  be  no  return  of  the  trouble. 
In  this  regard  we  must  not  only  examine  into  the  composition  of  the  food, 
but  take  into  consideration  the  method  of  preparation,  the  care  of  the 
bottles  and  nipples,  or  any  utensil  which  may  possibly  contaminate 
the  food.  Older  children,  who  are  fed  at  the  table_,  should  have  the 
diet  regulated. 

ACUTE  ILEOCOLITIS. 

Under  the  heading  of  Acute  Ileocolitis,  Enteritis,  Enterocolitis,  Inflam- 
matory Diarrhea  and  Dysentery  w-e  gather  a  group  of  cases  which  etiolcg- 
icallv  belong  with  the  acute  gastroenteric  infections,  since  thev  are  caused 
probably  by  the  same  infectious  agent  or  agents,  but  are  distinguished 
from  the  cases  of  simple  gastroenteric  infection,  first,  pathologically,  by 
the  presence  of  definite  and  more  or  less  marked  inflammatory  changes 
in  the  intestine,  and,  second,  clinically,  by  a  longer  course  and  a  greater 
mortality.  While  these  are  sufficient  grounds  for  the  separation  of  these 
disorders  and  their  separate  description,  it  is  to  be  understood  that  the 
dividing  line  is  not  at  all  definite  and  that  it  is  often  difficult  to  decide 
whether  a  given  case  should  be  classed  as  an  infection  without  definite 
organic  lesions  or  as  an  ileocolitis,  until  the  case  is  concluded,  possibly 
not  imtil  we  have  seen  the  results  of  autopsy. 


252  DISEASES  OF   THE  ALIMENTARY   TRACT 

For  the  most  part  the  etiology  of  ileocolitis  is  that  of  any  acute  gastro- 
enteric infection.  (See  p.  242.)  As  already  noted,  these  are  the  cases 
in  which  the  Shiga  bacillus  is  most  regularly  found. 

Etiology. — Ileocolitis  occurs  both  in  infants  and  in  children,  cases  being 
not  uncommon  up  to  the  age  of  five.  It  occurs  at  all  seasons  of  the  year, 
but  it  is  much  more  prevalent  in  the  summer  months.  It  may  follow  any 
of  the  acute  infectious  diseases,  such  as  measles  or  pneumonia.  It  is 
especially  common  among  the  poorly  nourished  and  debilitated  children 
resident  in  hospitals  or  asylums  or  in  the  tenement  districts  of  our  cities. 
It  may  follow  an  attack  of  cholera  infantimi,  or  acute  gastric  or  intestinal 
indigestion. 

Pathology. — The  inflammatory  process  affects  mainly  the  colon  and 
the  last  foot  or  two  of  the  ileum.  The  stomach  not  infrequently  shows 
the  changes  of  catarrhal  inflammation,  but  is  most  often  normal.  The 
upjjer  part  of  the  small  intestine  is  nearly  always  normal.  The  changes 
in  the  terminal  portion  of  the  ileum  may  be  quite  as  marked  as  those 
seen  in  the  colon.  The  ileocecal  valve  and  adjacent  parts  usually  show 
the  changes  to  an  exaggerated  extent.  There  are  three  different  types 
of  lesions  found  in  these  cases :  1.  Catarrhal.  2.  Ulcerative.  3.  Pseudo- 
membranous. 

1.  Catarrhal. — The  gross  appearances  in  this  condition  are  not  at  all 
impressive.  The  mucous  membrane  of  the  stomach  may  be  pale  or 
congested,  and  coated  with  mucus  which  is  often  stained  brown  from  the 
admixture  of  blood.  In  the  small  intestine  we  find  scattered  areas  of 
congestion  and  perhaps  slight  swelling  at  various  parts  of  the  gut; 
these  changes  may  be  found  even  in  the  upper  part.  With  the  con- 
gestion there  may  be  a  loss  of  superficial  epithelium  so  that  the  mucous 
membrane  looks  a  little  granular.  The  changes  are  usually  more 
marked  near  the  ileocecal  junction.  In  the  colon  like  conditions  prevail. 
The  congestion  may  be  found  throughout  or  only  in  the  lower  part, 
and  there  is  a  similar  loss  of  epithelium.  The  lymphatic  tissue  through- 
out is  usually  swollen;  the  Peyer's  patches  may  be  swollen  and  con- 
gested. Occasionally  there  is  a  superficial  loss  on  the  surface  of  the 
patches,  giving  them  a  moth-eaten  appearance.  In  severe  grades  of  this 
catarrhal  process  the  congestion  and  swelling  of  the  mucous  membrane 
may  be  marked  and  there  may  be  asense  of  thickening  in  the  wall  of  the  gut. 

Microscopically,  these  cases  show  some  loss  of  thesuperficial  epithelium, 
infiltration  of  the  mucous  coat  with  small  round  cells,  some  swelling  of 
the  lymphatic  structures,  injection  of  the  vessels  of  the  mucosa  and 
sulimucosa,  and  some  slight  degeneration  in  the  cells  of  the  tubules. 
The  changes  rarely  extend  deeper  than  the  mucosa,  and  the  muscular 
and  peritoneal  coats  are  normal. 

2.  Ulcerative. — The  ulcerative  lesions  seen  in  these  cases  are  of  two 
types — follicular  and  catarrhal.  The  ulcers  are  found  in  the  lower  ileum 
and  the  colon,  rarely  in  the  ileum  alone,  and  not  infrequently  confined 
to  the  colon.  In  the  follicular  type  the  ulceration  begins  in  the  solitary 
follicles,  which  swell,  degenerate,  liquefy,  and  are  destroyed.  In  most 
cases  the  ulceration  is  very  superficial,  producing  a  slight  dimpling  in 


DISEASES   OF  INTESTINES  IN  INFANCY  AND   CHILDHOOD     253 

the  surface  of  the  gut  corresponding  to  the  location  of  the  foUicIe.  The 
change  is  more  or  less  general,  so  that  there  are  numbers  of  these  little 
dimples  especially  on  the  surface  of 

the  colon.     If  the  changes  are  more     .-  —  .^^ 

advanced    and   the   follicles   entirely  } 

destroyed,  deep  ulcers  with  ragged,  ''/ 

overhanging    edges     are     produced.  ,  '! 

These  ulcers  may  extend  through  the  -  '  ._,, 

mucosa  and  submucosa  and  expose  I;  -  ", 

the  muscular  layer  of  the  wall.  Per- 
foration or  peritonitis  is  practically 
unknown.  Microscopically  we  find 
the  solitary  follicles  greatly  swollen 
and  projecting  on  the  mucous  sur- 
face, or  broken  down  and  undermin- 
ing to  some  extent  the  adjacent  mu- 
cosa, which  may  show  a  considerable 
infiltration  with  small  round  cells.  /  / 

In  the  so-called  catarrhal  ulcera-  '  / 

tion  the  loss  of  tissue  is  more  super-  -  j  ,• 

ficial  but  more  extensive  than  in  the         i 
follicular  ulceration.   The  destructive         V  1 

process  begins  about  the  solitary  fol-  •  , 

licles  of  the  colon,  the  mucosa  being  ^ '  ,  j 

destroyed    in    a   small  circular  area  ,/  7 

about  them.    The  fusion  of  adjacent         i  .  / 

ulcers  may  produce  a  large  ulcer  with  •  , 

irregular,  rounded   margins.     These 

large  ulcers   may  extend   about   the  ,  ,  *  / 

gut,  involving  a  considerable  part  of  '  '  /    '  /  U 

the  circumference.    Such  ulcers  may         *  ■     .' '  '  \a 

be  very  numerous  in  the  colon;  but  '  -  /«'[ 

few  are  found  in  the  ileum.  Micro- 
scopically we  find  the  mucosa  des- 


■-"i 


troyed  in  the  areas  of  ulceration  and        j  .  \      I 

the  surrounding  tissue  infiltrated  with  '  J 

small  round  cells,  the  infiltration  ex-        i  ■  *  ( 

tending  in  some  cases  deeply  into  the  ,  < 

submucosa.      Associated  with  either 

follicular  or  catarrhal  ulceration  there        ^  '  \      '^ 

may  be    the    general  changes  of   an       j  I 

acute  catarrhal  inflammation   in  the       I 

mucous  membrane  of  ileum  or  colon.  ^' 

3.  Pseudomembranous. — The  pseu-  •  ^i '      .  ■ 

domembranous  inflammation  is  also        —  i- 

seen   mainly  in  the   colon,  but    affects  Acute  membranous  colitis;  the  surface  every- 

,11                 "^                J.     f  J.I       •!                    'j.  where  roughened  by  the  membranous  exudate ; 

tne  lowermost  part  Ot  tne  ileum  quite  the  underlying  mucousmembrane  swollen  and 

regularly.       In    the    colon    the    whole  presenting  many  minute  superficial  erosions. 


254  DISEASES  OF   THE  AEIMEXTARY    TRACT 

mucosa  mav  l)e  involved  or  the  process  may  be  limited  to  certain  parts 
of  it,  j)articularly  the  rectum.  In  this  lesion  the  affected  parts  are  regu- 
larly thickenetl,  partly  by  the  exudate,  partly  by  infiltration  and  edema 
of  the  wall.  In  severe  cases  the  wall  may  be  several  times  its  normal 
thickness.  The  most  striking  feature  of  the  gross  specimen  is  the  yel- 
lowish or  grayish,  hbrinous  deposit  on  the  surface.  The  deposit  is  very 
rarelv  contimious  over  the  whole  nuicosa.  Usually  there  are  extensive 
areas  covered  with  pseudomembrane  with  intervening  areas  that  are 
normal  or  present  the  appearances  of  an  intense  catarrhal  inflammation, 
the  mucosa  being  swollen,  intensely  red  and  granular-looking,  like  raw 
meat  (Fig.  40).  There  may  be  minute  hemorrhages  into  the  mucosa 
either  in  these  areas  or  beneath  the  pseudomembrane.  The  membranous 
deposit  is  rarely  as  thick  as  that  seen  in  croupous  inflammation  in  other 
parts,  such  as  the  pharynx.  Usually,  it  consists  of  a  fine  fibrinous  layer 
that  is  easily  washed  or  brushed  off,  leaving  a  deeply  injected,  red, 
granular  surface  i)eneath.  Microscopically  the  pseudomembrane  is  seen 
to  consist  of  fibrin,  exfoliated  epithelium,  leukocytes,  and  some  red  cells. 
The  mucosa  beneath  shows  a  loss  of  the  superficial  epithelium,  infiltra- 
tion of  the  mucosa  and  submucosa  with  small  round  cells,  and  edema 
of  the  walls.    The  vessels  in  the  affected  areas  are  deeply  injected. 

In  any  of  these  pathological  conditions  of  the  intestinal  tract  numbers 
of  bacteria  can  be  found  on  the  surface  of  the  mucosa  and  within  its 
substance.  In  some  instances  the  bacteria  are  found  in  considerable 
niunbers  in  the  submucosa.  Some  enlargement  of  the  adjacent  lymph 
nodes,  the  retroperitoneal  and  especially  the  mesenteric,  is  a  regular 
accompaniment  of  these  lesions.  The  swelling  of  the  lymph  nodes  is 
regularly  proportionate  to  the  severity  of  the  process  in  the  intestine. 
On  section  the  lymph  nodes  may  be  injected,  pinkish  in  color;  more 
often  they  are  pale.  Microscopically  the  nodes  show  the  changes  of 
acute  hyperplasia. 

In  the  lungs  there  is  regularly  found  hypostatic  congestion  with  scat- 
tered areas  of  collapse.  In  a  large  percentage  of  fatal  cases  there  is  a 
more  or  less  general  bronchopneumonia.  The  kidneys  are  usually  a  little 
swollen  and  somewhat  soft,  the  cortex  pale  or  injected,  and  showing 
moderate  cloudiness.  Microscopically  we  find  the  lesions  of  acute 
degeneration.  Acute  nephritis  is  much  talked  of,  but  very  rarely  seen. 
The  spleen  is  usually  normal,  but  may  be  enlargerl  and  soft.  The  liver 
usually  shows  somewhat  more  fatty  infiltration  than  is  common.  I  have 
but  once  found  a  true  meningitis  in  association  with  an  ileocolitis. 

From  a  study  of  thirty-two  cases  of  fatal  infection  with  the  Shiga  or 
dysentery  bacillus,  Rowland  reports  that  the  pathological  lesions  may  be 
summarized  in  four  groups:  1.  A  pseudomembranous  inflammation, 
mainly  in  the  colon,  but  involving  the  lower  part  of  the  ileum.  2.  A 
hyperplasia  of  the  lymphoid  elements  in  both  large  and  small  intestine, 
in  one  case  in  the  colon  only.  The  lymph  follicles  are  hyperplastic,  the 
epithelium  over  them  is  deficient,  and  there  is  some  excavation  of  the 
follicles  themselves,  causing  "dimpling."  3.  A  superficial  necrosis  and 
ulceration  of  the  mucous   membrane  not  limited  to  the  follicles,  and 


DISEASES  OF  INTESTINES  IN  INFANCY  AND  CHILDHOOD     255 

not  accompanied  by  the  formation  of  pseudomembrane.  4.  A  group 
with  very  few  lesions  discoverable,  macroscopically  or  microscopically 
beyond  congestion,  moderate  hyperplasia  of  the  lymphoid  tissue,  and 
in  one  case  a  little  cellular  infiltration  of  the  superficial  part  of  the  sub- 
mucosa.  There  was  very  slight  histological  change.  The  slight  changes 
in  this  group  of  cases  were  mainly  attributable  to  the  fact  that  the  cases 
were  mostly  terminal  infectious  in  marantic  children,  whose  vital 
reaction  was  undoubtedly  poor,  and  in  whom  the  infection  ran  a  very 
short  course.  It  will  be  seen  that  these  four  groups  of  cases  correspond 
in  a  general  way  closely  with  the  several  classes  of  lesions  just  described 
as  comprised  under  the  designation  "ileocolitis."  The  lesions  of  the 
intestine  in  children  in  cases  of  infection  with  the  Shiga  bacillus  must, 
in  Rowland's  opinion,  be  conceived  to  be  of  two  kinds:  first,  those  due 
to  the  action  of  the  dysentery  bacillus  itself;  second,  those  due  to  the 
action  of  toxic  products  and  possibly  of  other  micro-organisms. 

Symptomatology .^The  mode  of  onset  and  the  later  course  of  cases  of 
acute  ileocolitis  varies  greatly.  It  may  be  a  primary  affection,  or  develop 
secondarily  to  one  or  more  attacks  of  acute  gastric  or  intestinal  indi- 
gestion or  gastroenteric  infection.  In  many  instances  it  is  a  terminal 
infection  in  children  already  exhausted  by  constitutional  disease,  rickets, 
syphilis,  or  tuberculosis,  or  by  acute  disease,  such  as  pneumonia,  measles, 
etc.  The  cardinal  symptoms  of  an  acute  ileocolitis  in  any  case  are 
fever,  which  may  be  high  or  low,  and  diarrhea  with  the  presence  of 
mucus  and  blood  in  the  stools.  We  may  distinguish  several  types  of  the 
disease  of  varying  severity. 

The  Severe  Type. — The  onset  of  the  disease  is  usually  sudden,  a 
sharp  rise  of  temperature,  102°  to  104°  or  105°  F.,  vomiting,  rapid  pulse, 
and  prostration.  The  vomiting  may  be  repeated,  but  is  not  usually 
severe.  After  a  few  hours  diarrhea  sets  in,  first  with  the  passage  of  the 
ordinary  intestinal  contents ;  then  the  color  of  the  movements  changes 
to  green  and  they  contain  undigested  food;  later  they  show  mucus  in 
considerable  amounts  and  usually  more  or  less  blood.  The  number  of 
stools  in  twenty-four  hours  varies  greatly,  from  six  or  eight  to  twenty 
or  more.  The  passage  of  a  stool  is  accompanied  with  pain  and  may  be 
followed  by  tenesmus.  With  the  full  development  of  the  diarrhea  and 
fever  nervous  symptoms  may  be  marked.  The  infants  or  children  are 
restless  and  fretful.  They  may  be  delirious  or  stupid,  or  coma  or  con- 
vulsions may  occur.  The  range  of  temperature  is  very  irregular  in 
these  cases.  For  a  few  days  it  is  high,  reaching  103°  to  105°  F. ;  usually 
then  it  takes  a  lower  range,  and  fever,  though  present,  is  not  marked, 
varying  from  99°  to  101°  or  102°  F.  The  pulse  remains  rapid,  the  eyes 
become  sunken,  the  fontanel  depressed,  and  the  evidences  of  exhaustion 
are  marked  in  the  attitude  and  action  of  the  child.  The  tongue  becomes 
coated  and  in  the  worst  cases  dry  and  brown,  the  lips  and  teeth  may  be 
covered  with  sordes.  The  appetite  is  lost  and  vomiting  may  occur 
frequently.  Thirst  is  usually  severe.  The  diarrhea  persists,  the  move- 
ments becoming  largely  mucous,  green  or  brown  in  color,  with  little 
blood;  later  in  the  disease  the  movements  are  often  foul.    Weight  and 


256 


DISEASES  OF   THE  ALIMENTARY   TRACT 


strength  arc  lost  rapidly.  At  any  time  the  course  of  the  affection  may 
he  modified  hy  the  development  of  a  hronchopneumonia.  After  running 
on  in  this  ^vay  for  one,  two,  or  three  weeks  the  children  die  of  exhaustion 
or  from  pneumonia,  or  they  begin  gradually  to  improve;  the  fever  dis- 
appears, the  diarrhea  lessens,  the  stools  become  more  fecal,  and  there 
may  be  a  slow  return  to  health.  In  any  case  convalescence  is  slow  and 
difficult;  the  patients  suffer  from  a  persistence  of  the  inflammatory  condi- 
tions in  the  bowel;  any  indiscretion  or  irregularity  increases  the  diarrhea 
and  prostration,  and  improvement  can  be  secured  only  by  great  care  and 
patience.     Even  after  beginning  to  improve  and  progressing  favorably 


June 


DATE 

25 

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n         1 

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130 

135 

150 

155 

160 

RESP. 

3C 

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30 

28 

30 

30 

38 

50 

Temperature  chart  of  a  case  of  eaterocolitis  in  a  child  aged  twenty  months.    Shiga  bacillus, 
alkaline  type,  isolated  from  stools. 

for  several  weeks  these  cases  suffer  relapses  and  die  of  their  disease, 
or  from  .some  complication,  in  most  instances  a  bronchopneumonia. 

In  the  most  severe  of  these  cases  all  the  symptoms  are  intense,  the 
fever  high,  the  diarrhea  severe;  mucus  and,  it  may  be,  blood  abundant; 
stupor  or  delirium  marked,  and  exhaustion  rapid,  so  that  the  children 
die  within  a  few  days  of  the  onset  (Fig.  47). 

In  these  .severe  cases,  when  fatal,  we  find  at  autopsy  either  an  acute 
catarrhal  or  pseudomembranous  ileocolitis.  The  recognition  of  the 
nature  of  the  pathological  lesion  before  death  can  be  safely  based  only 
on  one  or  both  of  the  following  points:    1.  Prolapse  or  profusion  of  the 


DISEASES  OF  IXTESTINES  IN  IXFANCY  AND   CHILDHOOD     257 

rectum  is  very  common  in  these  cases  and  in  some  cases  one  may  see  the 
prolapsed  membrane  covered  with  the  characteristic  deposit.  2.  Shreds 
of  membrane  may  be  found  in  the  stools.  If  the  stools  are  thoroughly 
washed,  bits  of  membrane  may  be  floated  out  in  the  water,  picked  out 
and  examined  microscopically.  If  the  presence  of  a  pseudomembranous 
inflammation  can  be  established  the  outlook  is  much  less  favorable  than 
in  the  acute  catarrhal  inflammation. 

The  Ordinanj  Type. — The  ordinary  type  of  the  disease  differs  from 
the  severe  only  in  degree.  The  onset  is  not  so  abrupt,  the  temperature 
not  so  high,  many  cases  running  their  course  with  temperature  not  above 
101°  to  102°  F.  (Fig.  48).    Vomiting  is  usually  not  marked  after  the  onset. 


Fig.  48 


DATE 

6 

J 

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a 

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Temperature  chart  of  a  ca'^e  of  enterocolitis  in  a  child  aged  seven  mouths. 


The  stools  are  numerous  and  have  the  usual  characters,  the  presence 
of  mucus  and  blood  being  the  essential  features.  The  blood  c[uickly 
disappears  from  the  stools  (usually  after  three  or  four  days),  and  these 
may  then  resemble  those  of  an  ordinary  diarrhea.  Griping  or  tenesmus 
are  usually  not  marked,  but  prolapse  of  the  rectum  is  not  uncommon. 
The  prostration  in  these  cases  is  marked,  but  not  extreme.  Weight  is 
lost  gradually.  The  cerebral  symptoms  are  ordinarily  slight.  The 
children  are  fretful  and  peevish,  or  may  be  stupid  for  some  days,  but 
delirium  or  coma  are  not  seen.  Most  of  these  cases  at  the  end  of  a  week 
shoAv  definite  signs  of  improvement  and  go  on  to  make  a  good  recovery. 
Convalescence  may,  however,  be  interrupted  by  relapses  and  in  unfavor- 
able conditions  the  affection  may  become  chronic  (Figs.  49  and  50). 
17 


258 


DISEASES  OF  THE  ALIMENTARY  TRACT 


111  Ihese  cases  we  are  probably  dealing  with  a  catarrhal  inflammation. 
If,  however,  after  two  or  three  weeks  the  diarrhea  still  persists,  with  the 
passage  of  foul  mucous  stools,  ulceration  of  the  bowels  should  be  sus- 
pected. Blood  in  the  stools  is  not  necessarily  an  indication  of  ulceration. 
We  have  seen  that  blood  is  regularly  present  in  the  early  stages  of  the 
disejise,  when  it  is  due  to  acute  congestion,  not  to  ulceration.  It  is  not 
infrequent,  on  the  other  hand,  to  find  abundant  ulceration  of  the  bowel 
in  cases  in  which  there  has  been  no  blood  in  the  stools.  The  duration  of 
the  disease  and  the  persistence  of  mucus  in  considerable  quantity  in 
the  stools  are  much  more  reliable  signs. 

Fig.  49 


DATE 

as 

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31              1 

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RESP. 

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20 

2b 

2» 

r.M  1 

Temperature  chart  of  a  case  of  enterocolitis  in  a  child  fourteen  months  old,  showiug  slight  fever 
and  subnormal  temperatures  ;  recovery. 


Fig.  50 

DATE             4 

":  lOf 

S  100 

D                 

:>          a 

1  1 

Ml 

=4# 

7              8             U            10           11           n 

1                                              ..  __ 

u          

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PULSE          IJO 

in            12b 

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-^^-"-- --------- ^--- 

lao        no        lib        lie         us        12 

tpil|li!|!.H|!iP 

)        no         no        iiB         iiB        112 

RESP.            -24 

22              2S 

24              24             22              24              22             2J 

24               24              24               24              20 

Temperature  chart  of  a  case  of  enterocolitis  in  a  child  twelve  months  old.  Shiga  bacillus,  acid  type, 
isolated  from  stools  ;  recovery. 


The  majority  of  the  cases  of  an  ordinary  type  recover,  but  in  infants 
below  the  age  of  six  months,  or  in  those  already  weakened  by  preceding 
disease,  the  affection  even  in  a  mild  form  is  very  fatal.  It  is  very  surpris- 
ing to  find  how  slight  the  organic  lesions  may  be  in  the  so-called  terminal 
infections. 

The  Suhacide  Type  (Follicular  Ulceration) . — This  type  is  most  often 
seen  in  sequence  to  a  number  of  attacks  of  acute  gastroenteric  infection. 
It  may  be  primary.  It  is  rarely  seen  under  six  months  of  age,  but  is 
frequent  from  the  sixth  month  to  the  end  of  the  second  year. 

The  attack  may  begin  wdth  a  sharp  rise  of  temperature  and  vomiting. 
More  often  the  onset  is  insidious  and  the  characteristics  of  the  condition 
are  not  shown  until  the  end  of  a  week.  In  these  cases  the  temperature  is 
but  little  elevated,  but  there  is  some  daily  fever;  usually  in  the  afternoon 
the  temperature  reaches  100°  to  101°  F.  Vomiting  may  occur  at  the 
outset  of  the  disease  or  at  rare  intervals  afterward,  but  is  not  a  feature 


DISEASES  OF   INTESTINES  IN  INFANCY   AND  CHILDHOOD     259 

of  this  condition.  Apart  from  the  low  fever  the  stools  are  most  char- 
acteristic. These  average  about  six  in  a  day  and  are  green  or  brown, 
often  foul  and  full  of  mucus.  Blood  may  be  present  in  small  quantities, 
never  in  large  amounts.  It  is  absent  more  often  than  it  is  found.  The 
tongue  is  usually  coated,  but  may  be  clean.  The  appetite  varies  greatly; 
more  commonly  it  is  lost  and  food  is  refused  completely.  The  persistent 
anorexia  may  be  one  of  the  most  troublesome  features  of  the  complaint. 
Cerebral  symptoms  are  usually  not  present.  With  the  low  fever  and 
the  mucous  stools  the  infant  steadily  loses  weight  and  wastes  until  the 
typical  picture  of  marasmus  is  developed.  The  fontanel  is  depressed, 
the  eyes  sunken,  the  face  deeply  wrinkled,  the  skin  hanging  loosely  on 
the  wasted  limbs  and  trunk,  and  the  abdomen  either  full  and  tense  or 
depressed  and  soft;  there  may  be  pressure  ulcers  upon  the  buttocks, 
heels,  or  occiput.  Gradually  the  strength  fails,  the  pulse  grows  weaker 
and  more  rapid,  and  at  last  the  child  fades  out  of  life.  Pulmonary 
symptoms  may  come  on  to  close  the  scene,  a  complicating  bronchitis  or 
bronchopneumonia  being  regularly  fatal.  The  cases  usually  run  three 
or  four  weeks.  On  the  other  hand,  some  cases  after  lingering  in  a 
critical  condition  for  weeks  gradually  begin  to  regain  strength.  The 
stools  improve  in  character  and  become  less  frequent;  the  temperature 
becomes  more  even ;  the  child  gradually  gains  strength  and  may  recover. 
Relapses  are  especially  frequent  in  this  condition,  and  any  one  of  them 
may  be  fatal.  Even  when  recovery  is  assured  the  child  still  shows 
sensitiveness  to  any  variations  in  food  and  diarrhea  is  easily  excited. 

The  essential  features  of  the  condition  and  the  only  basis  for  diagnosis 
are  the  low  fever  and  the  character  of  the  diarrhea;  the  stools  are 
frequent,  full  of  mucus,  and  possibly  with  a  little  blood.  The  course 
is  protracted,  usually  extending  over  three  or  four  weeks  and  sometimes 
longer.  There  is  no  definite  limit.  The  presence  of  ulcerations  undoubt- 
edly prolongs  the  disease  and  renders  recovery  more  difficult. 

Nervous  Symptoms  in  the  Diarrheal  Diseases  of  Children. — In 
any  type  of  these  acute  diarrheal  diseases  there  may  develop  very  marked 
and  puzzling  nervous  symptoms.  The  convulsions  of  the  onset  have  been 
spoken  of.  Later  in  the  course  and  usually  after  the  subsidence  of  the 
high  temperature  there  may  develop  the  condition  to  which  the  name 
hydrencephaloid  or  spurious  hydrocephalus  has  been  given.  The 
fontanel  is  depressed,  the  eyes  are  sunken,  the  head  is  drawn  back,  the 
pulse  is  irregular  or  intermittent,  the  respiration  is  irregular  and  may  be 
Cheyne-Stokes,  and  the  patient  is  restless  and  irritable  or  very  stupid, 
showing  no  desire  for  food  and  rousing  only  from  thirst.  The  picture 
is  very  suggestive  of  a  meningitis.  I  have  seen  it  made  even  more  so 
by  the  presence  of  strabismus  and  a  slow  pulse  in  addition  to  the  symp- 
toms already  named.  With  improvement  in  the  diarrheal  condition  these 
symptoms  regularly  subside.  The  explanation  of  these  nervous  symptoms 
has  been  variously  given.  It  is  known  that  meningitis  is  extremely  rare 
in  these  cases,  and  various  other  explanations  have  been  offered,  such 
as  cerebral  anemia  or  edema,  thrombosis  of  the  cerebral  sinuses,  or 
uremia.      Of  the  cerebral  conditions  named  it  is  only  necessary  to  say 


260  DISEASES  OF   THE  ALIMEXTARY   TRACT 

that  tlu'V  are  not  found  with  any  reffularity  in  association  with  the 
symptoms  mentioned  and  arc  seen  in  other  instances  without  them,  so 
that  one  cannot  accept  any  of  them  as  a  satisfactory  explanation.  It 
has  been  ah'eady  noted  that  true  nephritis  is  very  rarely  seen  in  these 
cases;  in  fact,  tliat  we  see  no  more  dcij<Micration  of  the  kidney  tlum  is 
seen  in  anv  other  acute  disease.  Uremia  cannot  therefore  be  reijarded 
as  probable.  Meningitis  is  one  of  the  very  rarest  complications  found  at 
autopsv  in  these  diarrheal  conditions.  I  have  seen  it  in  but  one  instance. 
In  anv  case  the  (juestion  can  usuallv  now  be  settled  by  the  results  of 
luini)ar  puncture.  In  the  failure  of  these  various  explanations  we  are 
for  the  present  c(Miipelled  to  fall  back  upon  the  hypothesis  that  these 
nervous  symptoms  are  produced  by  the  influence  of  toxins  on  the 
nervous  system. 

Diagnosis. — The  diagnosis  of  an  ileocolitis  is  usually  not  difficult. 
Under  acute  gastric  or  intestinal  indigestion  and  acute  gastroenteric 
infection  it  has  been  pointed  out  that  a  number  of  days'  observation 
may  be  required  to  determine  the  presence  of  ileocolitis.  If  in  any  of 
these  cases  the  febrile  disturbance  persists  for  a  week  or  more,  and 
there  is  a  diarrhea  with  mucus  and  blood,  particularly  the  latter,  in 
the  stools,  we  may  be  quite  sure  that  organic  lesions  have  been  estab- 
lished and  that  the  cases  may  be  classed  as  ileocolitis. 

The  question  of  the  possibility  of  typhoid  fever  occasionally  comes  up. 
A  continued  temperature  of  the  typhoid  type  is  decidedly  unusual  in 
these  cases.  As  already  noted,  after  the  acute  symptoms  of  the  onset 
have  passed  the  range  of  temperature  is  distinctly  lower  and  more 
irregular  than  is  seen  in  typhoid.  Some  cases  do,  however,  show  a  con- 
tinued fever  resembling  typhoid,  and  the  abdominal  distention  and 
diarrhea  add  to  the  resemblance.  The  absence  of  any  marked  enlarge- 
ment of  the  spleen,  of  the  characteristic  rash,  and,  finally,  of  the  Widal 
reaction,  enable  us  to  easily  exclude  typhoid  in  any  suspicious  case.  It 
is  also  to  be  noted  that,  except  in  communities  where  typhoid  fever  is 
rife  among  adults,  it  is  very  rarely  met  in  children  under  the  age  of 
five  vears,  and  still  more  rarely  in  infants.  At  the  Seaside  Hospital  of 
St.  John's  (ruild,  where  children  suffering  from  diarrheal  diseases  are 
sent  from  New  York  City,  among  several  hundred  cases  treated  every 
summer,  we  find  only  one  or  two  of  typhoid  fever.  In  Philadelphia  and 
Chicago,  on  the  other  hand,  typhoid  is  much  more  frequently  seen 
among  infants  and  children. 

The  onset  of  intussusception  is  often  marked  by  several  movements  of 
the  bowels  containing  blood  and  mucus,  and  these  cases  are  not  infre- 
quently looked  upon  and  treated  as  ileocolitis.  The  absence  of  fever, 
the  severity  of  the  pain,  the  absence  of  fecal  matter  from  the  stools  after 
the  first  movement  or  two,  and  the  presence  of  an  abrjominal  tumor  ought 
to  render  differentiation  easy,  when  the  possibility  of  confusion  is  remem- 
bered. 

Prognosis. — This  depends  upon  the  age  of  the  patient,  his  previous 
general  condition,  the  severity  of  the  attack,  and  the  promptness  of 
proper  treatment.     In  infants  under  the  age  of  six  months,  even  a  mild 


DISEASES  OF  INTESTINES  IN  INFANCY  AND   CHILDHOOD     261 

attack  of  ileocolitis  may  be  fatal.  In  older  children  who  are  in  good  con- 
dition and  are  properly  handled,  the  prognosis  is  good,  unless  the  onset 
of  the  disease  be  very  severe.  The  pseudomembranous  inflammation  is 
very  likely  to  result  fatally,  even  in  the  strong.  In  marantic  or  debili- 
tated children,  whatever  the  age,  an  attack  of  ileocolitis  is  very  likely  to 
be  fatal.  As  already  pointed  out,  it  is  surprising  to  find  how  slight  the 
lesions  are  in  many  of  these  terminal  infections.  Prompt  treatment  is 
of  importance  in  any  case.  Especially  in  dispensary  and  hospital  prac- 
tice we  see  numbers  of  cases  which  have  been  neglected  in  the  early 
stages  and  have  been  allowed  to  develop  a  condition  (probably  of  ulcera- 
tion) from  which  recovery  is  either  very  diflBcult  or  impossible,  when 
proper  care  in  the  beginning  would  unquestionably  have  determined  a 
more  satisfactory  result.  When  ulceration  has  taken  place,  recovery  is 
not  only  delayed,  but  in  many  cases  rendered  very  doubtful. 

Treatment.  Prophylaxis. — This  does  not  differ  from  the  prophylaxis 
of  any  of  the  gastric  or  enteric  infections  previously  dealt  with.  The 
most  important  point  with  relation  to  this  particular  disorder  is  to 
emphasize  the  necessity  and  advantage  of  early  treatment.  If  parents 
could  be  taught  that  any  diarrheal  disease,  in  the  summer  especially,  is  of 
great  danger  and  could  be  induced  to  put  these  cases  under  proper  care 
at  the  very  beginning,  the  mortality  could  undoubtedly  be  greatly  reduced. 

General. — This  must  be  carried  out  on  the  lines  laid  down  for  acute 
gastroenteric  infections  (p.  232). 

AVe  begin  treatment  by  thoroughly  clearing  the  stomach  and  intestinal 
tract,  by  washing  the  stomach  and  colon  with  normal  salt  solution,  and 
giving  a  purge  of  calomel  or  castor  oil.  We  cut  off  milk  feeding  until 
acute  symptoms  of  the  onset  have  subsided  and  the  intestinal  tract  has 
had  some  rest.  We  then  use  a  small  quantity  of  whey,  barley-water, 
broth,  beef-juice,  albumen-water,  or  one  of  the  malted  foods,  malted  or 
cereal  milk,  as  a  substitute  for  milk.  We  control  the  temperature  by 
baths  or  by  washing  out  the  colon.  After  the  subsidence  of  the  acute 
symptoms  we  begin  the  administration  of  milk  in  small  quantities  and 
in  dilute  mixtures.  We  treat  the  colitis  by  washing  the  colon  not  oftener 
than  once  or  twice  in  twenty-four  hours,  and  by  astringent  injections 
(Fig.  51).  We  give  stimulants  as  required.  Other  medication  is  limited 
to  the  use  of  some  intestinal  antiseptic. 

Hygienic. — The  general  care  of  these  patients  is  of  more  importance 
than  usual,  because  the  disease  is  likely  to  be  protracted  and  every 
factor  influencing  the  general  health  should  be  attended  to.  Removal 
from  the  city  is  of  the  first  importance.  The  patients  should  be  kept  in  the 
country  until  the  summer  is  over.  Return  to  the  city  during  the  summer 
is  regularly  followed  by  relapse.  Every  summer  a  number  of  children 
just  convalescing  from  an  ileocolitis  are  taken  from  the  Seaside  Hospital 
by  impatient  parents  and  brought  back  to  New  York.  The  result  is 
quite  regularly  a  fatal  relapse.  The  daily  bathing,  prompt  change  of 
soiled  diapers,  rest  in  bed,  and  quiet  are  essential.  x\s  Holt  says,  the 
cases  do  better  if  treated  separately  than  in  hospitals.  If  treated  in  hos- 
pitals, the  wards  should  be  small  and  contain  only  a  few  beds. 


262  DISEASES  OF   THE  ALIMENTARY   TRACT 

Dietetic. — The  ilietetic  management  of  these  cases  presents  tlie  most 
(hfficuk  problems  in  infant  feeding.  In  my  opinion,  whey  is  generally 
better  taken  and  borne  than  any  other  snbstitute  for  milk.  'J'he  (juan- 
tity  of  feeding  and  the  hours  must  be  regulated,  as  directed  on  p.  233, 
for  gastroenteric  infection.  There  is  no  rule  l)y  which  we  can  tell  what 
footl  is  best  to  give.  We  may  be  obliged  to  try  several  in  succession  before 
we  find  one  that  the  patient  will  take.  Some  infants  refuse  food  alto- 
gether, and  it  is  then  necessary  to  feed  by  gavage.  After  the  acute  symp- 
toms of  the  first  few  days  have  passed,  milk  nuiy  be  tried  in  snudl  (juan- 

FiQ.  51 


Method  of  washing  o\it  the  colon,  showing  the  position  of  the  child  and  the  height  of  the  reservoir. 


titles  and  well  diluted.  In  the  cases  in  which  the  fever  continues  high, 
milk  must  be  withheld  until  the  temperature  subsides.  If  the  patient 
is  taking  whey,  barley-water,  or  other  acceptable  diluent  for  a  milk 
mixture,  the  milk  may  be  added  to  this  very  gradually,  a  teaspoonful  to 
the  feeding  in  the  beginning.  If  milk  alone  is  tried,  it  should  be  given 
in  a  mixture  containing  not  more  than  2  per  cent,  fat,  6  per  cent,  sugar, 
and  1  per  cent,  proteid.  Peptonization  of  the  milk  is  often  of  advantage 
for  a  time,  but  should  not  be  long  continued.  AVhen  milk  is  once  begun, 
the  strength  of  the  mixture  must  be  very  slowly  increased.     Usually  a 


DISEASES  OF  INTESTINES  IN  INFANCY  AND   CHILDHOOD     263 

dextrinized  cereal  diluent  increases  the  digestibility  of  milk,  and  should 
be  tried  as  the  first  substitute  for  peptonization.  Relapses  are  frecjuent, 
and  require  again  the  administration  of  calomel  or  castor  oil  and  return 
to  weaker  feeding. 

Local. — As  the  colon  is  the  part  most  involved  in  the  inflammatory 
process,  local  treatment  is  of  especial  value.  In  the  early  stages  irriga- 
tion of  the  colon  should  be  employed,  care  being  taken  that  the  water 
is  carried  as  high  as  possible  into  the  colon  and  a  sufficient  quantity  of 
fluid  used  to  thoroughly  cleanse  it  (usually  a. gallon).  Such  irrigation, 
which  should  be  of  normal  salt  solution,  4  gm.  to  500  c.c.  (1  drachm  to 
the  pint),  may  be  repeated  twice  daily  in  the  beginning,  later  once  a  day 
or  once  in  two  days.  During  the  acute  stage  the  water  should  be  used  at 
a  temperature  of  98°  F.  Bleeding  is  rarely  sufficient  to  lead  one  to  hesitate 
in  the  use  of  the  irrigation.  So  long  as  the  reservoir  is  not  more  than 
two  or  three  feet  above  the  level  of  the  patient's  body,  no  danger  need  be 
apprehended  from  the  pressure  of  the  irrigating  fluid  (Fig.  51).  During 
the  acute  stage  the  irrigation  may  be  followed  by  the  injection  of  from 
60  to  120  c.c.  (2  to  4  ounces)  of  starch-water  containing  opium  for  the 
relief  of  pain  and  tenesmus.  For  an  infant  under  one  year  0.06  c.c. 
(1  drop)  of  the  tincture,  and  in  the  second  year  0.12  c.c.  (2  drops)  of 
the  tincture,  may  be  given  every  fiive  or  six  hours  in  this  way  to  keep  the 
patient  comfortable.  If  the  tenesmus  is  severe  0.015  to  0.030  gm. 
(i  to  2  grain)  of  cocaine  may  be  given  in  a  suppository. 

After  the  subsidence  of  the  acute  symptoms,  astringent  enemata  may 
be  used.  The  best  are  the  fluid  extract  of  hamamelis,  4  c.c.  (1  drachm) 
to  500  c.c.  (1  pint),  or  tannic  acid,  2  gm.  (^  drachm)  to  the  pint  of 
water.    Such  enemata  may  be  used  once  or  twice  daily. 

Medicinal. — It  is  very  doubtful  whether  antiseptics  given  by  mouth  are 
of  any  service  in  this  condition,  but  bismuth  or  salol  are  quite  regularly 
given.  Bismuth  should  be  given  in  quantities  of  at  least  8  gm.  (2 
drachms)  in  the  twenty-four  hours.  Salol  may  be  given  in  0.12  to  0.24 
gm.  (2  to  4  grains)  doses  every  four  hours.     (See  formuhe,  p.  235.) 

Stimulants  are  quite  regularly  required,  and  we  rely  mainly  upon 
alcohol  given  as  directed  on  page  236. 

Opium  may  be  given  by  mouth  for  the  same  indication,  and  in  the 
same  dosage  as  for  gastroenteric  infection. 

In  any  case  we  must  rely  more  upon  the  general  care,  diet,  and  local 
treatment  than  the  medication  for  cure. 


CHRONIC  ILEOCOLITIS. 

Chronic  ileocolitis  is  a  common  cause  of  chronic  diarrhea  in  infants, 
and  is  seen  not  infrequently  in  older  children. 

Etiology. — ^This  condition  is  regularly  the  sequel  of  one  or  more 
attacks  of  acute  ileocolitis.  The  cases  are  seen  most  often  in  the  fall 
among  infants  or  children  who  have  suffered  severely  from  acute  ileo- 
colitis but  have  survived  the  summer.     The  etiology  of  the  chronic 


2G4 


DISEASES  OF    THE   ALIMENTARY    TRACT 


Fig.  52 


affection  lies,  therefore,  in  the  causes  that  excite  the  acute  inflammation: 
had  hv<>;iene,  improper  food,  etc.  There  can  l)e  httle  douht  that  the 
factors  which  are  operative  in  producing  chronic  intestinal  indi<,a\stion 

may  also,  when    long  continued,  de- 
velop a  chronic  ileocolitis. 

Various  acute  diseases  may  also  he 
followed  hy  chronic  colitis,  esju'cialiy 
measles,  scarlet  fever,  lobar  pneumonia 
and  typhoid  fever. 

The  great  majority  of  the  cases 
must  be  in  the  end  referred  to  bad 
hygiene  and  bad  food.  The  cases  are 
common  under  the  age  of  two  years; 
after  that  age  thev  become  steadily 
less  frequent,  but  are  in  some  instances 
chronic,  (^olitis  is  seen  up  to  the  age 
of  ten  years. 

Pathology. — Often  the  gross  appear- 
ances of  the  intestine  in  these  cases  is 
very  disappointing.  It  may  look  al- 
most, if  not  quite,  normal.  The  lesions 
are  usually  limited  to  the  colon  and  the 
adjacent  part  of  the  ileum.  It  is  rare 
for  changes  to  be  found  in  the  upper 
part  of  the  small  intestine.  The  lym- 
phoid tissue  of  the  colon  and  lower 
ileum  is  o-enerallv  enlarged,  and  round 
about  the  mouths  of  the  solitary  folli- 
cles in  the  colon  there  is  some  dark 
pigmentation,  while  the  mucous  mem- 
brane, as  a  whole,  is  of  a  grayish  hue, 
giving  to  the  surface  the  "cut-beard" 
appearance  (Fig.  52).  The  wall  of  the 
gut  may  seem  thickened  in  some  cases, 
thinned  in  others.  "^Fhere  may  be 
ulcers,  either  of  the  catarrhal  or  follic- 
ular type,  but  they  are  quite  infre- 
quent, cases  with  ulceration  usually 
proving  fatal  before  the  condition  luis 
become  chronic.  The  catarrhal  ulcer- 
ation is  more  frequent  than  the  follic- 
ular for  like  reason.  In  this  case  the 
ulcers  are  very  superficial  and,  as 
Eustace  Smith  observes,  are  best  seen 
by  looking  oblicjuely  on  the  surface. 
They  may  be  on  the  summits  of  the  longitudinal  folds,  when  they  are 
long  and  sinuous,  or  between  them,  when  they  are  small  and  round. 
In  rare  instances  cysts  mav  be  found  in  the  mucous  membrane. 


Chronic  follieiilar  colitis;  solitary  follicles 
enlarged  and  pigmented ;  occasional  slight 
excavation  of  the  follicles. 


DISEASES  OF  INTESTINES  IN  INFANCY   AND   CHILDHOOD     265 

Microscopically  there  is  an  infiltration  of  both  mucosa  and  submucosa 
with  small  round  cells,  with  destruction  of  many  of  the  tubules  of  the 
mucous  membrane  due  to  compression.  In  long-standing  cases  there 
may  be  a  considerable  formation  of  connective  tissue.  These  changes 
are  not  continuous,  but  are  scattered  in  patches  through  the  wall.  The 
mesenteric  lymph  nodes  are  swollen  and  show  excessive  cell  proliferation. 

The  associated  lesions  are  found  most  regularly  in  the  lungs,  either 
in  hypostatic  congestion  or  consolidation,  or  as  a  bronchopneumonia. 
These  changes  are  regularly  found  in  the  lower  and  posterior  parts,  the 
anterior  parts  being  pale  and  bloodless. 

Symptomatolog-y. — In  whatever  way  established  the  essential  symp- 
tom of  chronic  ileocolitis  is  diarrhea.  In  the  early  stages  the  stools 
may  resemble  those  of  a  chronic  intestinal  indigestion.  They  inay  be 
■  abundant,  pultaceous,  lumpy  with  a  little  mucus,  or  grumous  and  more 
like  pus.  Gradually  they  lose  their  consistency,  become  thinner,  more 
frequent,  and  contain  more  mucus  and  undigested  food.  The  number 
varies  greatly;  in  some  cases  not  more  than  five  or  six  a  day;  in  others 
there  may  be  as  many  as  twenty  in  twenty-four  hours. 

The  color  varies  from  gray  or  green  to  dirty  brown.  The  constant 
features  are  the  presence  of  mucus  in  quantity  and  undigested  food. 

The  more  frequent  and  watery  the  stools  become,  the  less  apparent  are 
these  characters,  but  they  are  practically  constant.  When  the  stools 
are  few  in  number  it  is  quite  evident  that  they  consist  largely  of  mucus. 
Blood  may  be  found  in  the  passages,  but  rarely,  even  in  conditions 
where  ulceration  is  present.  With  this  chronic  diarrhea  there  are  the 
other  symptoms  which  belong  to  chronic  digestive  disturbances.  The 
children  are  irritable  and  peevish,  as  a  rule,  when  they  suffer  from 
flatulence  and  colic;  but  in  other  cases  where  they  are  free  from  pain 
they  are  singularly  placid  and  listless.  Vomiting  occurs  but  rarely. 
Food  is  usually  taken  eagerly.  The  abdomen  may  be  distended,  but  is 
rarely  tender,  and  is  often  retracted.  The  walls  become  thin  and  may 
show  the  veins  prominently;  but  the  veins  are  not  dilated.  About  the 
genitals  and  buttocks  there  may  be  considerable  redness,  or  even  ulcer- 
ations from  the  irritation  of  the  discharges.  The  other  symptoms  are 
those  of  marasmus  or  malnutrition.  The  fontanel,  if  open,  is  depressed. 
The  tongue  is  coated  in  some  cases;  in  others  red  and  glazed.  The  skin 
is  usually  of  a  peculiar  muddy  hue;  the  mucous  membranes  are  pale  and 
anemic.  The  facial  appearance  gives  the  baby  the  wizened  look  of  a  little 
old  man.  Upon  the  rest  of  the  body  the  skin  hangs  in  folds  with  almost  no 
subcutaneous  fat  and  little  muscle  beneath  it.  The  patients  may  increase 
in  stature,  but  do  not  gain  in  weight.  Eustace  Smith  states  that  in  this 
condition  dentition  may  be  continued  in  a  normal  manner.  The  temper- 
ature is  not  elevated  and  is  quite  regularly  subnormal,  sometimes  falling 
as  low  as  95°  F.  in  the  mornings.  J.  Lewis  Smith  used  always  to  say  that 
such  subnormal  temperature  was  a  sure  sign  of  approaching  demise. 
In  the  late  stages  edema  of  the  hands  and  feet,  gradually  becoming  more 
general,  may  be  seen  without  albuminuria.  The  urine  usually  shows 
no  abnormalities  of  importance.    The  circulation  is  poor  and  the  hands 


266  DISEASES  OF   THE  ALIMENTARY   TRACT 

and  feet  are  regularly  cold ;  the  pulse  is  weak.  The  respiration  is  feeble 
and  shallow.    The  eyes  are  usually  dear  and  bright. 

In  such  condition  an  infant  may  linger  for  weeks  or  months  and  then 
begin  to  slowlv  improve.  The  diarrhea  lessens,  the  stools  become  more 
normal  in  consistency,  and  the  infant  begins  to  show  some  animation. 
Eustace  Smith  makes  the  curious  observation  that  the  return  (;f  tears 
is  of  favorable  significance.  The  weight  may  begin  to  show  a  gain  and 
very  slowly  the  infant  makes  progress.  In  any  event  the  progress  is  very 
slow  and  relapses  are  frequent.  It  is  generally  several  years  before  a 
child  returns  to  normal  and  many  of  these  children  show  the  evidences 
of  their  loss  all  through  childhood. 

In  most  cases  strength  is  lost  gradually  until  death  ensues  from 
exhaustion,  or  from  a  complicating  bronchitis  or  bronchopneumonia. 
The  duration  of  the  disease  is  from  two  months  to  a  year.  Holt  says  that 
very  few  of  the  cases  survive  after  four  months. 

Diagnosis. — The  problem  in  this  relation  is  to  determine  whether  the 
intestinal  lesions  themselves  are  sufficient  to  account  for  the  condition 
or  whether  there  is  some  underlying  constitutional  disease.  Rickets  and 
syphilis  have  such  characteristic  signs  that  they  can  be  easily  recognized 
and  excluded  upon  the  results  of  the  physical  examination.  The 
greatest  difficulty  is  to  exclude  tuberculosis.  It  has  become  so  common 
to  speak  of  these  cases  as  consumption  of  the  bowels  that  a  misleading 
conception  of  them  has  become  quite  general.  As  a  matter  of  fact  very 
few  of  these  cases  are  tuberculous,  yet  from  time  to  time  we  find  tuber- 
culosis present  in  cases  in  which  it  had  not  been  suspected.  Tuberculosis 
is  certainly  more  common  in  children  in  hospitals  or  asylums  than  in 
general  practice.  It  is  to  be  considered  carefully  in  cases  with  a  tuber- 
culous family  history.  The  presence  of  pulmonary  consolidation  is  of 
some  importance.  If  this  involvement  is  in  the  posterior  and  lower 
parts  of  the  chest,  it  may  be  either  tuberculous  or  simple  broncho- 
pneumonia. If  the  consolidation  is  anterior,  it  is  almost  surely  tuber- 
culous (Holt).  In  any  case  of  pulmonary  involvement  it  may  be  possible 
bv  using  a  cotton  swab  to  secure  some  of  the  sputum  from  the  pharynx 
and  determine  the  presence  of  tubercle  bacilli.  In  the  tuberculous  cases 
the  abdomen  is  more  likely  to  be  distended  and  enlarged  mesenteric 
lymph  nodes  may  be  felt.  In  some  instances  tubercle  bacilli  may  be 
found  in  the  mucus  of  the  intestinal  discharges.  The  presence  of  blood 
in  the  stools  is  rare  in  any  case  and  is  not  distinctive. 

Prognosis.— The  age  of  the  patient,  the  surroundings,  and  the  severity 
of  the  diarrhea  are  the  principal  factors  in  determining  the  prognosis. 
Infants  under  the  age  of  six  months  regularly  do  badly.  The  prospect 
for  those  in  hospitals  or  asylums  is  decidedly  poorer  than  for  those  in 
private  families.  Ability  to  command  favorable  surroundings,  to  secure 
good  nursing,  and  to  carry  out  the  various  details  of  care  and  feeding 
is  of  great  importance.  The  severity  of  the  disease  depends  largely  upon 
the  presence  or  absence  of  ulceration.  There  are  no  decisive  symptoms 
of  the  presence  of  ulcers.  They  are  most  likely  to  be  present  in  those 
who  have  had  repeated  attacks  of  acute  ileocolitis.    The  more  protracted 


DISEASES  OF  INTESTINES  IN  INFANCY  AND  CHILDHOOD     267 

the  case  and  the  more  severe  the  diarrhea  the  greater  hkehhood  that 
there  are  ulcers.  The  older  the  child  the  better  the  prospect  of  recovery, 
especially  if  the  conditions  are  favorable  for  careful  systematic  treatment. 

Treatment.  Hygienic. — Fresh  air  with  protection  from  exposure  to 
cold  are  of  prime  importance.  During  the  summer  such  cases  must  be 
kept  out  of  the  cities.  In  the  fall  or  winter  the  sick-room  should  be  kept 
as  nearly  as  possible  at  a  temperature  of  68°  to  70°  F.  and  yet  be  well 
ventilated.  For  this  purpose  an  open  fire  is  particularly  desirable.  Two 
rooms  should  be  used  in  order  to  secure  proper  airing  and  cleaning 
without  exposure  to  the  patient.  Great  care  should  be  taken  in  bathing 
not  to  chill  the  patient.  In  bad  cases  Eustace  Smith  advises  a  bath  of 
one  minute  in  hot  soapsuds,  or  in  extreme  cases  he  forbids  bathing 
altogether,  except  local  sponging  after  each  stool.  A  flannel  binder 
should  be  worn  constantly  and  the  feet  protected  by  woollen  stockings. 
It  is  necessary  to  keep  the  feet  warm  in  all  cases,  and  where  this  cannot 
be  accomplished  otherwise  a  hot-water  bottle  should  be  kept  at  the 
feet.  Prompt  changing  and  removal  of  soiled  diapers  are  necessary. 
The  buttocks  and  genitals  should  be  carefully  cleansed  after  each  stool 
and  then  thoroughly  dusted  with  a  good  toilet  powder  to  prevent  irritation 
or  ulceration. 

Dietetic— Upon  the  proper  management  of  the  diet  in  these  cases 
the  hope  of  success  in  treatment  mainly  depends.  The  guiding  principle 
is  to  give  adequate  nourishment  in  such  form  as  to  leave  the  smallest 
possible  residue  to  irritate  the  inflamed  ileum  and  colon.  Farinaceous 
foods  must  be  cut  out  altogether  or  reduced  to  a  minimum.  The  pro- 
portions of  both  fat  and  proteid  must  be  greatly  reduced  to  meet  the 
weakened  digestive  power  of  the  infant.  The  best  materials  for  food  in  the 
early  stages  are  whey,  weak  veal-broth  or  chicken-broth,  and  barley-water, 
the  last  being  the  one  form  of  farinaceous  food  which  seems  to  be  well 
borne  in  these  cases;  it  may  be  dextrinized  with  advantage.  These 
foods  must  be  given  in  small  quantities,  at  intervals  of  not  less  than  two 
hours.  In  the  first  year  of  life,  as  a  rule,  not  more  than  six  or  seven 
feedings  should  be  allowed  in  twenty-four  hours ;  in  the  second  year  five 
feedings  are  sufficient.  At  the  outset  the  amount  allowed  at  one  feeding 
should  not  be  more  than  half  of  what  the  age  would  warrant.  Only  as 
the  digestion  improves  should  the  quantities  be  increased.  Any  of  the 
foods  recommended  for  the  later  stages  of  acute  ileocolitis  may  be  tried. 

After  a  week  or  two  upon  these  very  dilute  foods,  if  improvement  has 
begun,  peptonized  milk  may  be  tried.  The  peptonization  should  be 
complete  at  first  and  the  milk  may  be  added  in  small  quantities  to  the 
whey  or  barley-water,  or  given  by  itself.  The  peptonization  may  then 
be  gradually  reduced.  In  some  cases  fat  cannot  be  digested  and  it  is 
necessary  to  use  skimmed  milk. 

Cereal  or  malted  milk  may  also  be  given.  Scraped  beef  is  often  well 
borne  by  patients  over  a  year  in  age.  The  reason  for  employing  such  a 
number  of  foods  is  that  a  certain  variety  is  necessary  and  a  mixed  diet 
is  found  to  agree  better  than  a  more  monotonous  one.  Thus,  as  a  diet 
for  a  nine-months-old  infant,  beginning  to  gradually  return  to  milk  food, 


2G8  DISEASES  OF   THE  ALIMENTARY    TRACT 

Eiistace  Smith  recomiiuMKls  the  followiiii,':  First  meal:  One  teaspoonful 
of  Melhn's  food  dissolved  in  four  ounces  of  stcrihzed  milk  and  barley- 
water,  cfjual  parts.  Second  meal:  Four  ounces  of  veal-broth  of  the 
streni^th  of  a  j)ound  of  meat  to  the  pint  of  broth.  Third  meal:  P'our 
ounces  of  whev,  containin<^  a  dessertspoonful  of  cream.  Fourth  mcaJ: 
The  unboiled  yolk  of  one  e^f>i:,  plain  or  beaten  up  with  a  tablesj)ooiiful  of 
cinnamon-water,  a  little  white  sugar,  and  ten  drops  of  brandy.  Fijth 
meal:  Same  as  the  first. 

When  once  we  have  succeeded  in  getting  an  infant  to  digest  sufficient 
food  to  maintain  nourishment,  we  can  usually  by  gradual  increases 
secure  a  slow  gain.  In  the  early  stages  we  may  l)e  satisfied  to  avoid  loss, 
if  only  we  can  see  a  gradual  improvement  in  the  stools.  Efforts  to  hasten 
gain  in  weight  only  too  often  result  in  overtaxing  a  weakened  digestion 
and  increasing  the  syinj)toms. 

Local. — This  should  be  carried  out  as  directed  under  acute  ileocolitis. 
The  colonic  irrigation  may  be  carried  out  once  a  day  at  first;  later  every 
other  day.  The  astringent  enemata  should  be  of  service  used  in  the 
same  wav.  Pain  and  tenesmus  may  rerpiire  the  use  of  sedative  supposi- 
tories. Prolapse  of  the  rectum,  when  it  occurs,  is  produced  by  the 
relaxation  of  the  tissues  and  the  straining.  The  treatment  of  the  diar- 
rhea and  the  astringent  enemata  are  usually  sufficient. 

Medicinal. — Medicines  are  of  peculiarly  little  service  in  this  affection. 
In  beginning  treatment  or  with  any  increase  in  the  symptoms,  a  full  dose 
of  castor  oil,  4  c.c.  (1  drachm), for  a  child  under  a  year;  8  c.c.  (2  drachms), 
for  one  in  the  second  year;  or  calomel,  0.0()o  to  0.13  gni.  (1  to  2  grains) 
given  in  0.01  to  0.015  gm.  Q-  or  {  grain)  doses  hourly,  may  be  given. 
Excessive  peristalsis  or  pain  may  be  checked  by  occasional  doses  of 
opium,  O.Ol  to  O.Olo  gm  (}.  to  }  grain)  of  Dover's  powder  or  0.00  to  1  c.c. 
(10  to  15  minims)  of  jiaregoric  to  a  child  under  one  year.  Antifermen- 
tative  or  antiseptic  drugs  by  mouth  have  very  little  effect.  Bismuth 
mav  be  given  in  the  manner  described  on  page  235.  It  is  of  no  use  in 
small  doses,  and  unless  some  definite  effect  can  be  shown  from  its  use, 
it  had  best  be  omitted. 

Stinuilants  are  often  re(juired  in  conditions  of  exhaustion.  Alcohol 
in  some  form  should  be  given  as  described  under  Acute  Ileocolitis. 
Later,  iron  and  arsenic  may  be  employed.  In  very  wasted  children 
thorough  rubl)ing  with  some  oil,  once  daily,  seems  to  help  them.  Cod- 
liver  oil  has  no  special  advantage  to  recommend  it  for  this  purpose,  and 
any  l)land  oil  may  just  as  well  be  used,  or  cocoa  butter,  such  as  is  regu- 
larly employed  by  mas.seurs.  It  is  doubtless  the  rul)bing  and  not  the 
oil  that  does  the  good. 

COLIC. 

This  scientifically  Inaccurate  and  unsatisfactory  term  serves  such  a 
useful  purpose  in  practice  and  covers  so  well  a  multitude  of  abdominal 
pains  tluit  it  maintains  its  place  in  our  medical  books.  Under  the  term 
"colic"  we  comprehend  any  sudden,  sharp  pain  referred  to  the  abdo- 


DISEASES  OF  INTESTIXES  IX  IXFAXCY   AXD   CHILDHOOD     269 

men.  It  has  already  been  mentioned  in  connection  with  the  section  on 
artificial  feeding.  Any  of  the  acnte  inflammatory  diseases  of  stomach, 
intestines,  appendix,  or  any  of  the  other  abdominal  viscera  may  be 
accompanied  by  such  pain,  but  in  common  usage  these  are  not  con- 
sidered under  this  heading.  I  restrict  its  use  to  the  sudden,  sharp  pains 
due  to  disturbed  function  on  the  part  of  the  stomach  or  intestine,  and 
accompanied,  as  a  rule,  with  flatulence.  Even  in  this  more  limited 
signification,  colic  is  a  symptom,  not  a  disease,  but  it  often  so  dominates 
the  scene  as  to  demand  consideration  by  itself.  Colic  is  most  frequent 
in  the  early  weeks  of  life,  when  the  alimentary  tract  of  the  infant  is 
undeilaking  work  which  is  new  and  in  which  it  experiences  difficultv. 
In  most  instances  the  difficulty  lies  in  the  composition  of  the  food;  in 
other  cases  it  seems  to  be  an  inherent  lack  of  power  in  the  digestive 
organs  of  the  infant.  Colic  may  be  seen  either  in  nurslings  or  in  the 
artificially  fed,  more  frequently  in  the  latter.  The  most  reasonable 
explanation  of  the  occurrence  of  pain  is  that,  by  reason  either  of  the 
composition  of  the  food  or  weak  digestive  power,  or  both,  digestion  is 
imperfect  and  fermentation  occurs  with  the  production  of  gas  and 
resulting  distention  and  pain;  in  other  cases  it  may  be  that  there  is  no 
gas  but  a  local  spasm  of  the  intestine,  excited  by  the  presence  of  an 
irritant. 

In  most  cases,  either  in  nurslings  or  in  the  bottle-fed,  colic  is  pro- 
duced by  an  excess  of  proteids  in  the  food;  the  excess  need  not  be 
marked  to  produce  colic  in  a  susceptible  child.  In  some  cases  excess  of 
sugar,  particularly  of  cane-sugar,  may  be  responsible.  Excess  of  fat 
rarely  causes  colic. 

Overloading  the  stomach,  feeding  too  frequently  or  with  great 
irregularity,  giving  cold  milk  and  the  like,  and  exposure  to  cold  may 
in  other  cases  be  responsible  for  the  disturbance. 

Symptomatology. — Usually  the  symptoms  come  on  within  five  or  ten 
minutes  after  a  feeding.  The  baby  becomes  restless  and  fretful,  then 
begins  to  kick  uneasily,  bends  its  body  forward,  and  the  legs  up,  and 
cries  vigorously  and  piteously.  The  face  is  at  first  congested,  but  in 
severe  attacks  it  soon  becomes  pale,  with  a  certain  blueness  of  the  lips. 
The  hands  and  feet  are  usually  colder  than  normal.  The  crying  con- 
tinues for  a  few  minutes,  or  it  may  be  hours ;  then  gas  is  raised  or  passed, 
or  the  spasm  gradually  relaxes,  the  attack  passes  off.  These  attacks 
may  be  repeated  after  each  feeding,  or  only  occasionally.  Infants  are 
peculiarly  likely  to  sufi^er  during  the  evening  and  night,  and  in  bad  cases 
the  crying  is  almost  incessant.  "When  intestinal  distention  is  the  cause 
of  colic  the  symptoms  are  often  delayed  for  an  hour  after  feeding. 

The  colic  may  be  accompanied  with  other  symptoms  of  an  indigestion, 
frequent  vomiting,  diarrhea,  with  stools  green  and  containing  mucus, 
or  it  may  occur  in  babies  apparently  well  and  gaining  steadily.  In  the 
latter  case  it  is  more  often  associated  with  constipation,  the  movements 
being  dry,  hard,  and  lumpy.  The  attacks  of  colic  usually  persist  for 
weeks  or  months,  until  improvement  in  the  digestive  power  or  modi- 
fication of  the  feeding  brings  relief.     Infants  suffering  from  chronic 


270  DISEASES  OF    THE   ALIMEXTARY    TRACT 

gastric  or  intestinal  indigestion  frequently  have  attacks  of  colic  through- 
out the  course  of  their  disease. 

Prophylaxis. — In  this  is  involved  all  that  pertains  to  the  proper  feeding 
of  infants.  In  the  case  of  nurslings  irregularity  of  feeding  in  the  first 
few  weeks  is  often  the  cause  of  colic.  Clock-like  regularity  should  be 
enjoined.  Between  nursings  the  infants  should  be  kept  absolutely  quiet. 
Analysis  of  the  breast  milk  nuiy  show  irregularities  which  can  be  cor- 
rected. In  artificial  feeding  we  must  secure  the  proper  composition  of 
the  food,  the  regular  feedings  with  proper  quantities,  and  the  perfect 
cleanliness  of  every  step  of  the  feeding  process. 

Treatment. — For  the  milder  attacks,  peppermint-water,  2  to  4  c.c. 
(one-half  to  one  drachm),  is  a  househohl  remedy  that  is  often  helpful. 
0.30  to  0.60  c.c.  (five  to  ten  drops)  of  whiskey  or  gin  in  hot  water 
will  often  suffice  if  the  peppermint  does  not  give  relief.  Heat  to  the 
abdomen  and  extremities,  best  secured  by  letting  the  baby  lie  upon  a 
hot-water  bottle  in  the  nurse's  lap,  is  most  helpful.  If  these  fail,  or  the 
attack  is  severe,  relief  can  most  surely  and  promptly  be  had  by  washing 
out  the  colon  with  warm  water.  Some  prefer  simply  gi^'ing  an  enema  of 
four  ounces  of  warm  water,  or  two  ounces  of  cool  water  and  one-half 
teaspoonful  of  glycerin,  but  the  irrigation  is  more  prompt  and  effective. 
Care  should  always  be  taken  to  keep  the  feet  warm.  If  all  these  meas- 
ures fail,  the  pain  is  probably  due  to  spasmodic  action  and  opium  in 
some  form  will  be  required  for  relief.  Paregoric  may  be  given  in 
0.60  c.c.  (ten-drop)  doses,  repeated  in  half  an  hour  if  necessary.  The 
habitual  use  of  any  preparation  of  opium  for  the  relief  of  colic  should 
never  be  advised.  Starr  recommends  bromide  and  chloral  in  the 
following  form: 

P— Potassii  bromidi 1.0  gin.  (gr.  xvi). 

Chloral 0.5    "  (gr.  viii). 

Sjrrupi 15.0  c.c.  (Sss). 

Aq.  menthse  pip q.  s.  ad    50.0  "  (Sij).— M. 

Sig. — 4  c.c.  (one  teaspoonful)  for  a  dose,  repeated,  if  necessary,  every  hour  for  three  doses. 

After  the  remi.ssion  of  the  attack  the  cause  of  it  should  be  sought, 
especially  in  the  feeding,  and  efforts  made  to  correct  any  irregularities. 
It  may  be  necessary  to  omit  one  or  two  feedings  and  give  barley-water. 
Usually  with  care  the  frecjuency  of  the  attacks  can  be  decidedly  lessenetl, 
if  they  cannot  be  entirely  prevented.  As  the  baby  grows  older  and 
digestive  ])ower  increases,  the  frequency  of  attacks  tends  naturally  to 
become  less. 


CHRONIC  INTESTINAL  INDIGESTION. 

Chronic  intestinal  indigestion  may  be  met  with  at  any  period  of 
infancy  or  childhood,  but  it  is  particularly  common  from  the  sixth  month 
to  the  end  of  the  second  year. 

Etiology. — The  causation  of  this  condition  is  analogous  to  that  of 
chronic  gastric  indigestion.     The  difficulty  may  arise  from  weak  intes- 


DISEASES  OF  IXTESTIXES  IX  IXFAXCY  AXD   CHILDHOOD     271 

tinal  digestive  power,  which  may  be  either  congenital  or  acquired,  or 
from  overtaxing  or  improperly  using  a  normal  intestine.  There  seems 
little  question  that  a  certain  number  of  infants  are  born  with  deficient 
digestive  power,  especially  with  respect  to  the  intestine,  but  in  many- 
other  cases  the  normal  digestive  power  is  lowered  as  the  result  of  con- 
stitutional disease,  improper  care  or  unhygienic  surroundings,  over- 
crowding in  tenement  houses,  bad  air,  and  little  sunlight.  In  anv  of 
these  ways  a  child  may  be  rendered  unable  to  digest  proper  food,  and 
the  condition  develops  into  a  chronic  intestinal  disorder,  but  in  the  great 
majority  of  cases  the  cause  of  the  disturbance  is  to  be  found  in  improper 
feeding.  It  may  simply  be  overfeeding  with  food  of  proper  composition ; 
much  more  often  it  is  the  composition  of  the  food  which  is  at  fault.  In 
the  case  of  breast-fed  children  the  fault  most  often  lies  in  an  excess  of 
proteids  and  deficiency  of  fat.  In  some  instances  the  fat  may  be  in 
excess.  The  normal  milk-sugar  never  seems  to  disturb,  even  when  in 
excess.  In  the  artificiallv  fed  it  may  be  the  use  of  starchy  foods,  which, 
being  imperfectly  digested,  undergo  fermentation  and  decomposition  in 
the  intestine.  ^Nluch  more  often  here,  also,  it  is  excess  in  the  proteid  con- 
stituents of  the  food,  especially  if  cows'  milk  is  being  used. 

Experience  constantly  impresses  upon  us  the  fact  that  no  matter  how 
modified  or  manipulated  the  casein  of  cows'  milk  is  radically  different 
from  the  proteid  of  breast  milk,  that  it  cannot  be  taken  in  the  proportion 
of  the  proteid  of  the  latter,  and  that  even  in  minute  amounts  its  diges- 
tion is  a  very  diflScuIt  matter  for  some  children. 

In  any  of  the  ways  suggested  the  tax  put  upon  an  infant's  digestive 
powers  may  be  too  great  and  may  result  in  a  chronic  disturbance  of  the 
intestinal  functions.  In  the  nature  of  things  the  stomach  may  be  in- 
volved in  the  disturbance,  but,  if  so,  the  gastric  sjinptoms  are  limited 
to  occasional  vomiting.  The  intestinal  disturbance  is  the  main  feature 
of  the  cases  under  consideration. 

In  older  children  the  causation  of  intestinal  indigestion  is  similar: 
constitutional  disease,  bad  hygiene,  faulty  feeding.  In  these  cases  it  is 
likely  to  be  an  overindulgence  in  sweets,  pastry,  richly  cooked  and 
poorly  prepared  foods,  etc.  In  many  families,  as  soon  as  a  child  is 
weaned,  it  is  admitted  to  the  family  table  and  allowed  to  participate  in 
the  common  food,  what  ever  that  may  be.  Of  these  children  it  is 
commonly  said  "They  can  eat  ami:hing." 

Pathology. — ^Theoretically  these  cases  would  show  no  organic  lesions. 
Practically  infants  die  with  symptoms  only  of  chronic  intestinal  indiges- 
tion, and  we  find  that  they  show  some  of  the  lesions  of  a  chronic  colitis, 
thickening  of  the  wall  of  the  gut,  enlargement  of  the  solitary  follicles,  or 
pigmentation  about  them,  etc.  Xo  definite  line  exists  between  the  two 
affections.  Doubtless  most  cases  belonging  in  this  category  would  show 
no  organic  lesion. 

Symptomatology. — The  affection  usually  develops  insidiously.  It  may, 
however,  follow  an  attack  of  acute  gastric  or  intestinal  indigestion.  The 
most  constant  symptom  is  looseness  of  the  bowels.  The  movements  are 
not  very  many  in  the  day,  five  to  six,  and  are  passed  without  straining, 


272  i)isi:.\SKs  OF  Till-:  MJMi:.\TAin'  tract 

with  little  or  no  j)ain.  Thov  consist  of  uiuli^cstod  food,  water,  and 
imicus.  The  imicus  is  not  in  lar<fi'  amounts,  except  durint;  exacerbations 
of  the  afi'ection,  and  i)l()od  is  never  present.  The  colf)r  of  the  passages  is 
noarlv  always  green,  mingled  with  which  are  the  white  flakes  or  curds 
of  undigested  ca.sein.  Fat  may  appear  in  the  stools  in  yellowish  masses, 
which  are  readily  soluble  in  alcohol  or  ether.  The  odor  of  the  stools 
mav  be  impleasant,  but  it  is  not  foul.  The  diarrhea  varies  from  time 
to  time,  with  periods  of  improvement,  when  the  stools  become  nearly 
normal  in  number  and  appearance,  or,  again, constipation  may  supervene. 

In  the  bad  cases  the  diarrhea  persists,  the  stools  become  gradually 
worse,  until  they  do  not  differ  from  those  of  a  chronic  colitis.  In  the 
milder  cases  there  may  be  periods  of  some  length  when  the  stools  are 
normal. 

Apart  from  the  disturbance  of  the  bowels,  the  chief  symptoms  are 
fretfidncss  and  failure  to  gain,  or  actual  loss  in  weight.  The  infants  do 
not  appear  to  suffer  much  from  pain,  but  they  are  restless,  peevish,  fretful, 
and  sleep  badly.     They  may  have  attacks  of  colic. 

The  crving  and  fretting  of  an  infant  with  this  disturiiance  may  l)e  a 
very  important  matter  to  a  family,  permitting  very  little  rest  or  sleep 
for  anyone,  so  long  as  it  continues. 

Often  the  early  signs  of  rickets,  beading  of  the  ribs,  slow  closure  of 
the  fontanel,  and  delayed  dentition,  develop;  in  other  instances  these  are 
absent,  and  the  infants  increase  in  stature  and  cut  their  teeth  in  a 
normal  way.  The  weight,  if  it  increases  at  all,  does  so  very  slowly;  often 
it  remains  stationary,  or  there  is  a  lo.ss.  With  this  loss  in  weight  the  fat 
disappears,  the  abdomen  usually  becomes  retracted,  the  eyes  and  fon- 
tanel are  sunken,  the  skin  hangs  loosely  in  folds,  but  usually  remains 
clear,  the  eyes  are  clear  and  bright,  and,  except  for  the  wasting,  the 
infants  may  not  appear  sick.  The  temperature  is  normal  or  even  below 
normal,  the  pulse  is  usually  rapid  and  weak,  the  infant  is  anemic  and 
verv  languid,  and  lies  almost  motionless  l)y  the  hour.  In  bad  cases  the 
infant  gradually  develops  a  marantic  condition  and  dies.  In  favorable 
cases  the  diarrhea  gradually  lessens,  the  stools  improve,  the  weight 
slowly  increases,  the  flabby  skin  fills  out,  and  the  infant  gradually 
becomes  normal  in  appearance.  The  duration  of  the  disease  may  be 
months  or  even  years. 

Infants  in  this  condition  may  present  various  unusual  nervous  symp- 
toms. Tetany  is  not  infrequent;  retraction  of  the  head,  irregularity  of 
the  respiration,  sudden  flushing  of  the  skin  in  large  areas,  and  urticaria 
or  other  eruptions  may  be  seen.  The  buttocks  and  genitals  may  become 
reddened  and  inflamed  by  the  discharges  from  the  bowels;  I  )ed -so  res  may 
develop  on  the  occiput,  buttocks,  or  heels.  From  time  to  time  these 
infants  have  exacerbations  of  the  affection,  attacks  of  severe  intestinal 
colic,  perhaps  a  little  fever,  and  an  increase  in  their  diarrhea.  It  may 
be  very  difficult  to  find  a  definite  cause  for  these  changes  in  the  coiu'se 
of  the  affection. 

While  chronic  intestinal  indigestion  is  most  frequent  during  infancy, 
it  is  not  at  all  uncommon  in  older  children.     At  this  time  it  may  be  a 


DISEASES  OF  INTESTINES  IN  INFANCY  AND   CHILDHOOD     273 

natural  sequence  of  the  disturbance  of  the  earUer  period,  or  it  may  be 
produced  by  recent  irregularities  of  life  and  diet.  Overfeeding,  espe- 
cially with  carbohydrates,  indulgence  in  pastry,  candies,  etc.,  are  the 
common  causes.  The  affection  is  persistent  and  demands  care.  Chil- 
dren do  not  grow  out  of  it  without  this. 

Symptomatology  in  Older  Children. — These  are  very  variable,  both  with 
respect  to  the  intestine  and  to  the  disturbances  secondary  thereto.  The 
condition  of  the  bowels  varies  in  different  patients  and  in  any  individual 
from  time  to  time.  Constipation  is  much  more  common,  the  movements 
being  gray  or  brown,  putty-like,  and  being  expelled  only  with  straining. 
When  diarrhea  is  present  the  movements  are  gray  or  brown,  rarely 
green,  watery,  and  contain  undigested  food,  sometimes  mucus.  The 
children  are  poorly  nourished,  anemic,  small  of  stature,  muscularly 
weak.  The  prominence  of  the  head  and  abdomen  in  contrast  with  the 
thin  body  is  often  very  striking.  The  tongue  is  usually  coated,  but  may 
be  red  and  glazed.  The  appetite  is  lost  or  is  very  capricious.  The  abdo- 
men is  often  protuberant  and  tympanitic,  but  not  necessarily  so.  The 
face  is  pale;  there  are  dark  rings  beneath  the  eyes;  the  children  are  lan- 
guid, easily  exhausted  by  exertion,  peevish,  and  fretful.  Various  eccen- 
tricities are  developed  out  of  the  play  between  the  evident  physical 
weakness  of  the  child  and  the  sympathy  of  indulgent  parents.  The 
children  usually  become  thoroughly  "spoiled."  If  without  appetite,  they 
will  hardly  touch  food;  if  hungry,  on  the  other  hand,  they  gratify  the 
craving  with  whatever  the  fancy  suggests.  They  are  indulged  in  every 
way  to  their  harm,  and  not  infrequently  both  disposition  and  character 
are  spoiled  in  the  process. 

The  children  often  suffer  from  nervous  symptoms  of  more  or  less 
severe  type.  Headache  is  most  common,  and  may  be  of  the  migraine 
type.  Retraction  of  the  head,  tetany,  attacks  of  stupor  or  unconscious- 
ness, and  convulsions  may  occur.  From  time  to  time  the  condition  is 
made  worse  by  some  new  indiscretion  in  diet  or  life,  and  the  patients 
have  acute  attacks  of  pain,  more  diarrhea,  and  possibly  fever.  Fever 
may  also  arise  from  an  autointoxication  at  any  time.  Otherwise  the 
temperature  is  normal  or  below  in  conditions  of  exhaustion.  The  circula- 
tion is  regularly  poor;  the  hands  and  feet  are  always  cold.  The  urine  in 
these  cases  is  usually  loaded  with  indican,  the  amount  of  indican  being 
in  proportion  to  the  fermentation  going  on  in  the  intestinal  tract.  Lessen- 
ing of  the  amount  of  indican  is  a  valuable  guide  in  the  management  of 
these  cases.  Unless  cured  by  proper  treatment  these  cases  drag  on  for 
years,  finally  dying  of  exhaustion  or  passing  into  the  condition  of  con- 
firmed dyspeptics. 

Thomson,  of  Edinburgh,  has  recently  shown  me  two  cases  of  chronic 
diarrhea  in  young  men,  in  which  there  had  been  marked  failure  of 
development,  the  patients  being  still  boys  in  appearance,  small  in 
stature,  with  beardless,  boyish  faces,  the  high-pitched  voice,  the  unde- 
veloped genitals  of  youth.  In  addition,  there  were  a  peculiar  sallow, 
muddy  complexion  and  marked  lassitude.  The  stools  in  both  cases 
had  been  proven  to  be  largely  composed  of  the  fat  ingested,  the  diarrhea 
18 


274  DISEASES  OF    THE  AUMEXTARY   TRACT 

beinj;  apparently  due  to  a  failure  of  the  digestion  of  fat.  It  was  thought 
that  tliis  failure  might  be  due  to  a  defective  pancreatic  secretion,  and  one 
case  had  been  treated  with  the  pancreatic  extract  for  some  time,  with 
the  result  of  an  increase  of  several  inches  in  stature  in  a  few  months  and 
marked  improvement  in  all  other  respects. 

Treatment. — Whatever  the  age  or  condition  of  the  patient,  proper 
treatment  involves  the  regulation  of  the  life,  the  most  favorable  arrange- 
ments with  regard  to  light,  air,  exercise,  bathing,  sleep,  etc.,  that  are 
possible.  The  matter  of  clothing  is  of  especial  importance,  since  the 
circulation  is  always  \yooT  and  hands  and  feet  cold.  Except  in  con- 
ditions of  great  exhaustion,  these  patients  should  be  kept  out-of-doors 
as  much  as  possible.  If  necessary',  they  may  be  sent  out  in  a  carriage 
with  hot-water  bottles  to  the  feet,  but  under  any  circumstances  they 
should  get  fresh  air.  If  confined  to  the  house,  the  sick-room  should  be 
the  best  the  house  affords  for  light  and  air;  in  winter  preferably  heated 
bv  an  open  fire.  The  temperature  of  the  room  should  be  kept  at  68° 
to  70°  F.,  as  a  rule,  but  if  the  child  cannot  be  taken  out-of-doors,  it  may 
be  wrapped  up  well  and  the  windows  opened  for  an  hour  morning  and 
afternoon.  If  the  child  is  too  weak  to  warrant  that  measure,  then  it 
must  be  removed  into  another  warm  room  for  an  hour  or  two  daily, 
while  the  sick-room  is  aired  and  warmed  again.  The  infant  or  child 
should  have  a  daily  bath  at  such  temperature  as  is  consistent  with  a 
good  reaction.  The  utmost  care  should  be  given  to  the  child's  cleanliness 
and  comfort. 

The  dietetic  management  of  these  cases  is  the  keynote  of  the  treatment. 
In  Infanis:  If  breast-fed,  the  mother's  milk  should  be  analyzed.  For 
this  purpose  the  contents  of  a  breast  should  be  taken,  the  breast  being 
thoroughly  emptied,  as  the  composition  of  the  milk  is  known  to  vary  so 
in  the  first  and  in  the  latter  part  of  nursing  time.  Such  analysis  may  be 
made  bv  the  method  described  by  Shaw,*  or  more  satisfactorily  by  an 
analytical  chemist.  Analysis  of  the  milk  will  sometimes  show  irregular- 
ities which  can  be  corrected,  or  it  may  be  that  inquiry  as  to  the  mother's 
life  will  reveal  conditions  that  should  be  changed.  As  a  general  rule, 
whatever  is  best  for  the  mother's  health  will  tend  to  favor  the  infant's. 
If  in  this  way  or  from  the  infant's  stools  we  can  get  a  clue  to  the  source 
of  difficulty  it  may  be  that  modifying  the  mother's  life,  as  suggested 
under  Gastric  Indigestion,  may  serve  to  set  the  matter  right.  The 
quantity  taken  by  the  child  at  a  nursing  must  be  considered  also,  and 
determined  by  weighing  the  infant  before  and  after  a  nursing.  By 
regulating  the  nursing-time  we  can  cut  off  any  excess  that  may  be 
shown,  although  I  have  found  that  the  amount  taken  at  any  one  nursing 
often  varies  greatly  without  apparent  reason.  If  the  disturbance 
continues  despite  these  measures,  the  infant  should  be  weaned  or  a 
wet-nurse  obtained.  It  is  not  wise  to  allow  an  infant  in  whom  the  signs 
of  intestinal  disturbance  continue  to  go  on  nursing.  In  breast-fed  babies 
it  is  best  to  stop  at  once  the  food  that  is  being  taken,  give  0.065  gm. 

'  Archives  of  Pediatrics,  1903,  vol.  xx.  p.  578. 


DISEASES  OF  INTESTINES  IN   INFANCY  AND   CHILDHOOD     275 

(1  grain)  of  calomel  in  divided  doses,  and  then  put  the  infant  on  a 
modified  milk  mixture  suitable  to  its  age.  Thus,  in  an  infant  of  less 
than  three  months,  we  should  use  a  mixture  containing  2  per  cent,  fat, 
6  per  cent,  sugar,  and  0.66  proteid;  for  a  child  of  three  months,  a  mixture 
of  3  per  cent,  fat,  6  per  cent,  sugar,  and  1.0  per  cent  proteid;  for  a  child 
of  six  months,  a  mixture  of  4  per  cent,  fat,  7  per  cent,  sugar,  and  2.0  per 
cent,  proteid.  These  mixtures  should  be  given  in  quantities  and  at 
intervals  suited  to  the  infant's  age.  This  done,  the  inspection  of  the 
stools  will  show  what  part  or  parts  of  the  food  are  not  digested;  these 
must  be  accordingly  reduced.  We  should  not  rest  satisfied  until  the 
stools  are  normal.  It  is  quite  remarkable  on  what  minute  quantities 
of  cows'  milk  an  infant  can  be  nourished  if  only  the  milk  given  is  digested. 
Most  often  it  is  the  proteids  that  are  at  fault,  the  fat  less  frequently,  and 
the  sugar  least  of  all.  It  is  very  rarely,  as  stated  before,  that  sugar  is 
given  in  excess;  the  limit  of  tolerance  is  much  higher  than  with  either 
of  the  other  constituents.  Usually,  we  find  it  necessary  to  reduce  both 
fats  and  proteid  to  a  low  level,  in  cases  of  any  length  of  standing.  Some 
infants,  even  at  six  or  eight  months,  will  not  digest  more  than  2  per 
cent,  fat  and  0.25  per  cent,  proteid,  and  yet  upon  mixtures  suited  to  their 
digestive  abilities  will  slowly  gain.  We  must  not  expect  to  see  these 
infants  gain  normally  for  some  time.  If  they  can  be  kept  comfortable 
and  a  gain  of  an  ounce  or  two  recorded  in  a  week,  we  may  be  quite  sure 
that  they  will  in  the  end  do  well.  As  improvement  comes,  the  strength 
of  the  milk  mixture  may  be  increased  very  carefully,  a  fraction  of  a 
per  cent,  at  a  time.  Usually  the  power  to  digest  fat  increases  more 
rapidly  than  that  of  proteid.  Every  increase  must  be  made  conditionally. 
If  evidences  of  undigested  food  appear  in  the  stools,  the  food  must  be 
reduced  to  the  previous  level  and  kept  there  for  some  time.  If  one  can 
tide  a  patient  through  a  winter  or  summer  in  this  way,  until  a  time  of 
the  year  is  reached  when  he  may  be  safely  and  comfortably  kept  out-of- 
doors  for  hours  at  a  time,  more  rapid  improvement  can  be  expected. 
Especial  care  is  necessary  through  the  summers  from  the  great  dangers 
of  more  serious  intestinal  disturbance. 

In  some  cases  cows'  milk  is  better  digested  if  diluted  with  some  cereal 
water — barley-water,  for  example.  If  cereals  are  used  it  is  desirable  to 
dextrinize  them  by  the  use  of  one  of  the  diastatic  ferments. 

In  other  cases  the  milk  may  be  peptonized  with  advantage.  If 
peptonization  is  tried,  it  should  be  prolonged  until  the  peptonization  is 
complete;  partial  digestion  seems  to  be  of  no  value. 

It  may  be  that  some  patients  cannot  take  milk  in  any  form.  Such 
should  be  given  egg-albumen  water,  whey,  chicken,  mutton -broth  or  beef- 
broth,  and  beef-juice  for  several  days  or  a  week,  and  then  the  milk  tried 
again  in  very  small  quantities. 

There  is  always  a  temptation  in  these  cases  to  experiment  with  one 
or  another  of  the  patent  foods,  and  it  must  be  admitted  that  in  some 
instances  the  experiment  succeeds,  but  in  most  instances  it  fails.  W^e 
have  no  means  at  present  of  knowing  which  cases  will  do  well  and  which 
not.    Nor  is  there  any  one  of  these  foods  which  can  be  especially  recom- 


27()  DISEASES  OF   THE   ALIMENTARY    TRACT 

mended.  If  such  foods  are  to  he  used  at  all,  care  should  he  taken  to 
select  one  that  contains  no  free  starch.  If  we  find  an  infant  that  has 
already  been  put  on  one  of  these  foods  and  is  comfortable  upon  it,  we 
shall  do  well,  Jis  a  rule,  to  employ  the  food  as  a  basis  for  giving  milk, 
adding  the  latter  in  teiispoonful  (piantities  to  each  feeding  at  first,  and 
gradually  increasing  the  amount  of  milk  while  lessening  the  quantity  of 
the  food  until  tolerance  is  established  for  milk.  The  solution  of  the 
difficulty  in  nearly  all  cases  is  to  get  the  infant  to  digest  an  adequate 
(juantity  of  cows'  milk,  and  by  one  or  other  of  the  methods  given  above 
we  may  hope  for  success. 

Lavage  of  the  colon  is  useful  as  part  of  the  treatment.  Salt  solution, 
from  1000  to  2000  c.c.  (1  to  2  quarts),  may  be  used  until  the  colon  is 
completely  cleared  of  its  contents.  This  lavage  is  to  be  used  daily,  until 
im])r()vemcnt  is  begun;  then  it  is  to  be  used  only  on  alternate  days. 

Medicines  are  of  secoiulary  importance,  but  seem  to  be  of  some 
value.     The  following  prescription  is  often  of  service: 

{t— Bismuth,  subnitrat 8.0  gm.  (5ij). 

Elixir  lactopeptin 8.0  c.c.  (5ij). 

Mist,  cret q.  s.  ad  120.0  "  (Siv). 

Sig. — 1-8  c.c.  (3j  to  3ij)  after  each  feeding. 

In  older  children  the  treatment  is  often  difficult  because  the  control 
of  the  dietary  is  much  harder  to  establish.  The  co-operation  of  the 
parents  must  be  secured.  If  not,  the  child  had  better  be  put  entirely 
in  the  control  of  a  competent  nurse,  who  will  carry  out  orflers.  All  the 
measures  relating  to  general  hygiene  are  of  importance,  especially 
fresh  air  and  exercise  without  fatigue.  In  the  diet  it  is  essential  to 
exclude  the  starches,  sugars,  pastry,  hot  breads  or  cake,  fruits,  and  all 
higlilv  seasoned  foods.  The  diet  should  be  mainly  nitrogenous  and  as 
bliind  as  po.ssible.  ]\Ieals  should  be  ordered  at  regular  hours  and  nothing 
allowed  between  them.  During  the  second  year  five  meals  a  day  are 
sufficient  and  four  for  the  third  or  fourth  year.  ^Nlilk  should  be  the  chief 
food  at  first.  In  severe  cases  the  milk  should  be  peptonized.  If  fat 
cannot  be  digested,  the  milk  should  be  skimmed.  Kumy.ss  or  matzoon 
mav  be  used  as  substitutes  for  milk  and  are  sometimes  better  borne  than 
milk  itself.  Junket  may  be  used  for  the  same  purpose,  or  chicken-,  mutton- 
or  beef-broth.  ^leat  may  be  given  as  scraped  meat,  or  finely  cut  beef- 
steak or  roast  beef.  The  soft  parts  of  oysters  may  be  given  occasionally 
instead  of  meat.  A  good  diet  is  as  follows:  Breakjasi,  8  a.m.,  one  or 
two  glasses  of  milk,  with  dry  toast;  a  soft-boiled  egg  may  be  added 
every  other  day.  Luncheon,  12  M.,  a  teacupful  of  junket  or  a  cup  of 
broth  and  one  or  two  Boston  crackers.  Dinner,  3  p.m.,  a  tablespoonful 
or  two  of  chicken,  roast  beef  or  beefsteak  with  toast  or  zwieback;  the 
soft  parts  of  six  or  eight  raw  oysters  may  be  given  as  a  substitute  for 
the  meat,  two  or  three  times  a  week.  Supper,  7  p.m.,  a  glass  or  two  of 
milk  and  toast. 

After  such  a  diet  has  been  followed  for  several  weeks,  vegetables  may 
be  added  to  the  dinner,  a  tablespoonful  of  spinach,  cauliflower,  asparagus 
tops,  or  celery,  well  cooked,  being  allowed  at  a  time. 


DISEASES  OF  INTESTINES  IN  INFANCY   AND   CHILDHOOD     277 

If  the  patients  are  constipated  on  such  a  diet,  a  tablespoonful  of 
MeUin's  food  may  be  added  to  each  glass  of  milk,  or  the  juice  of  an 
orange  allowed  each  morning.  If  medicines  are  necessary.  Holt  espe- 
cially recommends  calomel,  a  full  dose,  0.065  to  0.13  gm.  (1  to  2  grains), 
being  given  at  night,  and  followed  by  a  saline  in  the  morning.  This 
may  be  given  to  any  case  with  advantage  every  five  or  six  days. 

It  is  doubtful  whether  any  of  the  antiseptics  usually  recommended 
are  of  service  in  checking  the  fermentative  processes  in  the  intestine, 
but  some  physicians  have  great  faith  in  them.  Salol  may  be  given  in 
5-grain  powders  four  times  a  day  or  the  salicylate  of  soda  in  the  following 
form: 

Jfc— Sodii  hyposulphitisi 0.75  gm.  (gv.  x). 

Sodii  salieylatis 8.00    "  (gij). 

Aquae  menthee  pip 120.00  c.c.  (Siv).— M. 

Sig.— 3.75  c.c.  (5j)  in  water  four  times  a  day,  after  meals. 

It  is  of  the  utmost  importance  with  respect  to  final  success  that  the 
diet  be  persisted  in  for  many  months.  Relapses  may  be  easily  caused 
by  any  indiscretion  in  the  diet,  and  the  whole  process  have  to  be  repeated. 


CHRONIC  CONSTIPATION. 

As  with  intestinal  colic,  so  with  chronic  constipation,  the  condition  is 
often  only  a  symptom,  as  in  rickets  or  pyloric  stenosis,  but  the  symptom 
is  of  so  much  importance  as  to  warrant  its  separate  description  and 
consideration. 

Etiology. — The  causes  of  chronic  constipation  are  many;  it  is  difficult 
to  classify  them  all. 

1.  Anatomical. — Undoubtedly  the  relative  length  and  the  many  con- 
volutions of  the  infant's  intestine  favor  constipation,  most  of  all  the  long 
sigmoid  flexure.  The  length  of  this  part,  its  distention  and  the  thinness 
of  its  walls  are  very  striking  in  the  infant.  It  is  not  very  unusual  in 
autopsies  on  children  to  see  the  sigmoid  extending  over  into  and  filling 
the  right  side  of  the  abdomen. 

Pyloric  stenosis  is  another  anatomical  cause  for  constipation  which 
has  of  recent  years  been  assuming  importance.  In  this  case  the  constipa- 
tion is  due  simply  to  the  limitation  of  the  amount  of  food  passing  into 
the  intestine.  Bands  and  adhesion  in  cases  of  chronic  peritonitis  may 
interfere  with  normal  evacuation  of  the  bowels,  but  they  very  rarely 
come  into  play  in  childhood.  They  are  occasionally  seen  after  opera- 
tion for  appendectomy. 

2.  Functional. — Deficiency  of  the  normal  secretions  of  the  liver  and 
intestine  is  sometimes  seen,  the  stools  then  being  gray-colored  and  hard. 
Sluggishness  of  peristalsis  from  some  lack  of  proper  nervous  tone  is 
undoubtedly  quite   regularly   a  factor  in  the   production   of  chronic 

1  The  sodium  hyposulphite  is  added  to  prevent  the  mixture  from  turning  black,  as  it  will  do  with- 
out the  bleacher. 


278  DISEASES  OF   THE  ALIMENTARY   TRACT 

constipation.    It  is  jilso  seen  in  nervous  disorders,  such  as  hydrocephalus, 
clu-onic  nieiiinifitis,  and  tlie  lik(>. 

Inhihition  may  sonietinies  conic  into  ])lay  in  producing  constipation; 
an  ulcer  of  the  rectum  or  hemorrhoids,  hy  reason  of  fear  of  pain,  may 
lead  a  child  to  restrain  the  movements  of  the  bowels. 

3.  Muscular. — This  is  usually  spoken  of  as  a  muscular  atony,  a 
comhiiicd  weakness  and  loss  of  irritability,  seen  as  the  result  of  consti- 
liitioiial  disease,  such  as  rickets  or  malnutrition,  or  from  lack  of  excrcis<\ 
The  nnisclcs,  l)oth  voluntary  and  involuntary,  are  poorly  developed, 
weak  and  lacking  in  tone,  and  the  bowels  are  de])rived  of  the  mechanical 
suji])ort  and  pressure  which  they  should  normally  have. 

4.  Dietetic. — -The  cause  of  chronic  constipation  in  both  infants  and 
children  is  most  often  found  in  some  deficiency  or  irregularity  in  the 
food.  In  breast  milk  it  is  most  often  a  deficiency  in  fat  with  an  excess 
of  proteid;  there  may  be  deficiency  in  both  these  elements.  In  artificial 
feeding  it  is  usually  lack  of  both  fat  and  proteid  in  the  early  months. 
Later,  it  maybe  the  use  of  sterilized  milk;  and  in  children  in  the  second 
or  third  year  a  too  exclusive  milk  feeding,  or  lack  of  the  starches  and 
sugars  which  should  be  supplied  in  a  mixed  diet. 

5.  Habits. — Simple  lack  of  training  can  cause  constipation  both  in 
infants  and  children.  In  some  cases  there  is  coupled  with  this  the 
habitual  use  of  opium  for  the  relief  of  colic,  or  of  purgative  drugs  to 
relieve  the  constipation. 

Symptomatology. — There  is  considerable  variation  both  in  infants  and 
children  as  to  what  constitutes  normal  evacuation  of  the  bowels.  During: 
the  first  year  an  infant  ordinarily  has  from  two  to  four  soft  movements 
daily;  in  the  second  year  one  or  two.  On  the  other  hand,  some  infants 
do  perfectly  well  with  but  one  soft  stool  daily.  If  the  movements  are 
dry,  hard,  and  passed  with  effort,  the  infant  is  constipated,  even  if  having 
two  or  three  such  passages  in  a  day.  In  bad  cases  of  constipation  an 
infant  or  child  may  go  two  or  three  days  without  a  movement. 

The  symptoms  produced  by  constipation  vary  greatly.  In  many 
instances  the  infant  or  chikl  suffers  only  from  the  difiiculty  in  evacuating 
the  bowel.  Prolapse  of  the  rectum  or  hemorrhoids  may  be  produced  by 
the  straining.  Often  the  infants  suffer  from  colic  and  flatulence,  have 
little  appetite,  are  restless  and  fretful,  particularly  at  night,  and  have 
occasional  attacks  of  vomiting  and  fever.  It  is  not  uncommon  to  see 
a  sudden  rise  of  temperature  to  102°  or  103°  F.  and  vomiting  due  to 
constipation.  The  restlessness  and  sleeplessness  are  often  marked  in 
both  infants  and  older  children.  Convulsions  may  be  produced  by 
constij)ation  in  susceptible  infants. 

In  older  children  the  symptoms  are  not  so  severe  as  in  infants,  but 
these  often  suffer  from  colic,  disturbance  of  digestion,  headache,  restless- 
ness in  sleep,  languor,  and  irritability,  have  a  muddy  complexion,  and 
show  defective  nutrition. 

The  stools  are  usually  small,  dry,  hard,  and  lumpy.  They  may  be 
passed  with  much  straining,  and  may  then  be  coated  with  mucus  from 
irritation  of  the  rectum,  or  blood  from  hemorrhoids. 


DISEASES  OF  WTESTlNES  IN  INFANCY  AND  CHILDHOOD     279 

Diagnosis. — The  history  is  usually  perfectly  clear,  but  may  be  mis- 
leading. In  any  case  of  doubt  the  movements  should  be  inspected,  and 
it  may  be  found  that, though  the  bowels  are  moving  daily, the  movements 
are  insufficient  and  of  a  distinctly  constipated  character. 

Prognosis. — The  affection  is  regularly  chronic,  and  may  take  months 
or  years  for  relief.  If  neglected  the  results  may  be  serious  in  infants, 
and  convulsions  may  be  produced  by  an  aggravated  condition.  In  older 
children  the  headaches,  digestive  disturbance,  and  debility  produced  by 
constipation  may  be  of  grave  importance.  With  proper  care  every  case 
can  be  corrected.  In  certain  families  the  tendency  to  constipation  seems 
to  be  hereditary, and  great  difficulty  maybe  encountered  in  overcoming  it. 

Treatment.  Hygienic. — Life  in  the  open  air  and  sunlight  are  of  value 
in  any  case,  but  especially  in  those  with  muscular  atony.  In  children 
old  enough  to  run  about,  care  should  be  taken  to  see  that  they  get 
sufficient  exercise.  Water  should  be  given  freely,  especially  in  summer, 
even  to  children  at  the  breast. 

Dietetic.  In  Nurslings. — If  the  mother's  breast  milk  is  over-rich 
in  proteid  and  low  in  fat,  efforts  must  be  made  by  combining  diet  with 
exercise  to  modify  the  character  of  the  milk.  If  the  breast  milk  is 
poor  in  both  fat  and  proteid,  full  feeding  and  rest  should  bring  about 
improvement. 

Where  the  deficiency  is  mainly  in  the  fat  this  may  be  corrected  by 
giving  one  to  two  teaspoonfuls  of  cream  (4  to  5  per  cent.)  after  each 
feeding.  Olive  oil  may  be  used  for  the  same  purpose.  Water  must  be 
given  to  these  children,  especially  in  summer;  and  in  an  infant  over 
three  months  of  age,  oatmeal-water  may  be  used  for  its  laxative  effect. 
In  infants  over  six  months  of  age  the  juice  of  half  an  orange  may  be 
given  every  morning  with  advantage.  If  these  measures  fail  we  had  best 
resort  to  suppositories  or  enemata  until  such  time  as  the  child  can  be 
weaned.  In  aggravated  cases  artificial  feeding  should  be  resorted  to 
if  these  measures  fail  to  give  relief. 

In  artificial  feeding  it  is  usually  necessary  to  increase  the  proportions 
of  both  fat  and  proteid,  but  the  proportions  of  the  food  must  not  be 
carried  far  beyond  the  proportions  ordinarily  employed.  Thus,  a  child 
under  three  months  of  age  is  not  likely  to  do  well  on  more  than  3  per 
cent,  fat,  6  per  cent,  sugar,  and  1  per  cent,  proteid;  a  six-months-old 
child  may  be  given  4  per  cent,  fat,  7  per  cent,  sugar,  and  2  per  cent, 
proteid.  Raising  the  proportions  much  beyond  these  limits  is  likely 
to  produce  indigestion,  but  if  increases  are  made  gradually  this  may 
be  avoided.  In  most  cases  distinct  benefit  can  be  had  from  the  use  of 
oatmeal- water  as  the  diluent  of  the  food. 

To  infants  of  six  months  or  over  the  juice  of  half  an  orange  may  be 
given  the  first  thing  in  the  morning,  and  as  the  age  increases  the  quantity 
of  juice  allowed  may  be  increased.  The  orange-juice  is  usually  enjoyed 
and  is  effective.  Beef-juice  may  also  be  given,  a  teaspoonful  three 
times  a  day  at  first,  the  quantity  being  increased  if  it  is  well  borne. 
Bovinine  and  like  preparations  are  also  laxative,  probably  from  the 
glycerin  in  them. 


280  DISEASES  OF   THE  ALIMENTARY    TRACT 

In  the  second  year,  instead  of  usinij;  oatmeal-water  as  a  diluent  of  the 
milk,  we  may  employ  an  oatmeal  jelly,  addin<^'  a  tahlesjjoonful  to  each 
bottle.  Additional  cream  may  also  be  given,  a  tablespoonful  to  each 
bottle,  but  it  is  rarely  advisable  to  raise  the  percentage  of  fat  above  4. 
The  orange-juice  and  beef-juice  may  be  used  in  larger  amounts — the 
juice  of  a  wliole  orange  and  from  \  to  1  ounce  of  beef-juice.  Later, 
oatmeal- or  wheat-j)orri(lge  may  be  given  with  cream.  All  l)read  allowed 
should  be  nuide  of  whole  wheat  or  bran,  and  butter  should  be  used 
liberally.  Cooked  fruits  are  especially  valuable:  baked  apples,  stewed 
prunes,  or  figs.  Of  the  latter  two  fruits  only  the  juice  should  be  allowed 
at  first.  Later,  the  pulj)  nuxy  be  given  finely  mashed.  Scraped  apple 
may  also  be  allowed  in  the  latter  j)art  of  the  year.  Li  aggravated  cases 
it  mav  be  well  to  reduce  the  milk  feedings  to  a  minimum  and  use  cream 
only,  giving  it  upon  porridge,  mixed  with  potato  or  rice,  or  in  soups  and 
brotlis.  From  4  to  S  ounces  may  be  allowed  daily.  Meat  is  to  be  given 
once  a  day  and  green  vegetal)les  allowed  with  it. 

In  older  children  the  same  general  lines  are  to  be  followed.  Milk  is 
to  be  limited  or  excluded.  Fat  given  freely  in  cream  or  butter.  Only 
whole  wheat  or  bran  bread  used,  and  abundance  of  fruit,  either  raw  or 
stewed,  given  daily.  Water  should  also  be  allowed  freely.  Vichy  or 
A})ollinaris  water  may  be  preferable  to  the  ordinary  supply. 

Local. — Massage  of  the  abdomen  should  be  employed  for  ten  minutes, 
once  or  twice  daily,  the  course  of  the  colon  being  followed  in  the  move- 
ments. Cool  sponging  of  the  abdomen,  followed  by  friction  with  a 
coarse  towel,  until  the  surface  is  reddened,  will  also  be  helpful. 

Suppositories  are  of  service,  especially  in  infants,  while  the  other 
measures  mentioned  are  being  put  in  fgrce,  or  in  case  they  fail  to  produce 
the  desired  effect.  In  many  instances  it  seems  that  the  only  defect  is  a 
lessened  irrital)ility  of  the  rectum,  and  even  a  slight  irritation  may  be 
sufficient  to  produce  a  movement.  For  this  purpose  a  cone  of  oiled 
paper  or  a  pencil  of  castile  soap  is  inserted  in  the  rectum  and  held  for 
two  or  three  minutes.  By  employing  such  a  measure  after  the  morning 
bath,  even  infants  in  their  first  months  can  soon  be  trained  to  have  a 
movement  at  that  time.  If  these  means  are  not  sufficient  a  gluten  or 
glycerin  suppository  may  be  used.  The  glycerin  is  the  more  irritating, 
and,  therefore,  more  effective,  but  it  is  always  best  to  employ  the  mildest 
measure  that  accomplishes  the  purpose.  Enemata  are  still  more  active. 
Simple  injections  of  warm  water,  GO  to  175  c.c.  (2  to  6  ounces),  may  be 
used.  To  increase  the  effect,  glycerin  may  be  added,  3.75  to  7.50  c.c. 
to  ()0  c.c.  (1  or  2  drachms  in  an  ounce)  of  water. 

In  cases  of  fecal  impaction  15  c.c.  to  30  c.c.  (^  ounce  to  1  ounce)  of 
warm  olive  oil  may  be  injected  and  allowed  to  remain  for  six  hours, 
then  followed  by  simple  enemata  of  warm  water  or  soapsuds. 

Medicines. — If  the  measures  outlined  above  fail,  it  may  be  necessary 
to  give  medicines  by  mouth,  but  their  use  is  objectionable,  especially 
if  it  is  to  be  continued  any  length  of  time,  and  it  is  desirable  to  reduce 
the  use  of  medicines  and  stop  them  as  soon  as  possible.  Medicines 
which  will  stimulate  the  flow  of  bile  are  indicated  when  constipation  is 


DISEASES  OF  INTESTINES  IN  INFANCY  AND   CHILDHOOD     281 

accompanied  with  pale-gray  or  whitish  stools.  Calomel  in  small  doses 
may  be  given  from  time  to  time,  but  it  cannot  be  kept  up.  Phosphate 
of  sodium,  in  doses  of  from  0.130  to  0.324  gm.  (2  to  5  grains),  may  be 
given  in  the  food,  three  times  daily,  to  an  infant  of  six  months.  It  may 
also  be  given  in  the  following  form: 

9;— Sodil  phosphatis 2.0  gm.  (gr.  xxx). 

SjT.  mannae 75.0  c.c.  (Sijss). 

Aq.  anisi q.  s.  ad    100.0  "  (siij).— M. 

Sig. — 4  c.c.  (one  teaspoonful)  three  times  daily  for  a  child  under  one  year. 

The  carbonate  of  magnesium  may  be  given  in  0.06  to  0.12  gm.  (about 
1  or  2  grains)  doses  in  a  little  milk,  or  the  milk  of  magnesia  in  doses  of 
4  c.c.  (1  teaspoonful)  to  a  child  under  one  year. 

For  systematic  use  nothing  is  better  than  cascara  sagrada,  either  in 
the  fluid  extract  or  an  elixir,  0.30  to  0.60  c.c.  (5  to  10  drops)  of  the 
first,  1.3  c.c.  (20  drops)  or  more  of  the  other.  In  each  case  the  amount 
required  for  a  daily  movement  is  to  be  determined  by  trial,  and  the  dose 
regulated  accordingly.  In  most  cases  the  dose  can  be  gradually  reduced. 
For  children  over  six  months  of  age  the  preparations  of  malt  with 
cascara  are  very  palatable,  from  2  to  4  c.c.  (\  to  1  teaspoonful)  may  be 
given.  Maltine  and  cascara  sagrada  or  Trommer's  malt  are  com- 
monly used. 

Treatment  may  be  briefly  summarized  thus :  In  any  case  rely  mainly 
upon  diet,  hygiene,  and  massage.  In  infants,  if  these  fail,  use  supposi- 
tories, the  mildest  that  will  be  effective,  or  enemata,  if  necessary.  We 
may  be  quite  confident  that  with  increase  in  the  strength  and  variety 
of  the  food  these  measures  can  be  abandoned.  ^Medicines  are  to  be 
employed  only  in  case  of  necessity,  and  are  to  be  discontinued  as  soon 
as  possible.  The  dosage  required  must  be  found  by  trial,  and  effort 
made  to  gradually  reduce  it. 


CHAPTER   XTII. 

JAUNDICE-DISEASES  OF  THE  LIVER^INTUSSUSCEPTION— APPEN- 
DICITIS-DISEASES OF  THE  PERITONEUM— INTESTINAL 
PARASITES. 

ACUTE   GASTRODUODENITIS   (CATARRHAL   JAUNDICE). 

Acute  Gastroduodonitis  or  Catarrhal  Jaundice  is  a  rare  disease  during 
childhood  and  is  almost  unknown  in  infancy.  It  is  assumed  that  the 
primary  comj)laint  in  these  cases  is  a  catarrhal  inflammation  of  the 
stomach  and  duodenum,  resulting  in  such  swelling  of  the  mucous 
membrane  of  the  duodenum  as  to  obstruct  the  opening  of  the  bile-duct, 
or  extending  into  the  duct  itself  and  blocking  the  duct  by  the  swelling 
of  its  own  lining.  The  minute  size  of  the  common  bile-duct  in  infancy 
and  childhood  certainly  renders  obstruction  easy,  and  if  our  present 
views  of  the  causation  of  catarrhal  jaundice  are  correct,  it  is  difhcult 
to  understand  why  this  affection  is  not  much  more  common  in  childhood, 
seeing:  that  catarrhal  inflammations  of  the  stomach  and  intestine  are  so 
frequent.  There  is  some  ground  for  the  view  that  catarrhal  jaundice 
is  a  specific  infectious  disease. 

Etiology. — So  far  as  known  this  is  that  of  any  acute  gastric  catarrh, 
errors  in  diet,  exposure  to  cold  or  wet,  etc.  It  is  said  to  occur  particularly 
after  some  one  of  the  acute  infectious  diseases — influenza,  malaria,  etc. 

Pathology.— We  have  no  opportunity  to  examine  the  viscera  in  these 
cases,  and  all  that  can  be  said  is  that  we  would  expect  to  find  the  ordinary 
evidences  of  catarrhal  inflammation  in  the  stomach  and  duodenum  with 
sufficient  swelling  to  obstruct  the  flow  of  l)ile  at  the  papilla  of  Vater. 

Symptomatology. ^The  affection  begins  insidiously  with  the  symptoms 
of  a  mild  gastric  catarrh,  a  coated  tongue,  nausea,  possibly  vomiting,  a 
sense  of  weight  or  oppression  in  the  epigastrium,  and  some  depression. 
There  may  be  tenderness  in  the  epigastrium  and  some  slight  enlarge- 
ment of  the  liver.  On  the  second  or  third  day  the  jaundice  appears  in 
the  conjunctivte  and  skin  and  gradually  deepens  for  a  day  or  two.  The 
tongue  becomes  more  heavily  coated,  the  nausea  and  possibly  vomiting 
continue,  the  urine  is  bronze-tinged  with  bile  and  is  scanty,  the  bowels 
are  constipated,  and  the  feces  become  gray  or  white  in  color.  There  is 
usually  a  marked  depression,  but  the  severe  nervous  or  cerebral  symp- 
toms, associated  with  the  condition  of  cholemia,  are  rarely  seen.  Neither 
is  the  slowing  of  the  pulse  or  respiration,  nor  the  distressing  itching  of 
the  skin  common  in  childhood.  The  jaundice  reaches  its  maximum  in 
two  or  three  days  and  then  gradually  clears  up,  all  symptoms  remitting 
with  it.  The  duration  of  the  disease  may  be  considered  as  two  weeks, 
( 282  ) 


DISEASES  OF   THE  LIVER  283 

but  the  pigmentation  of  the  skin  may  be  perceptible  for  some  time  after 
all  symptoms  have  disappeared. 

Diagnosis. — The  manner  of  onset  and  the  presence  of  jaundice  are 
characteristic.  Except  in  early  infancy,  when  jaundice  occurs  either 
from  congenital  obstruction  of  the  bile  passages  or  from  the  disturbances 
of  portal  circulation  incident  to  birth,  or  the  extremely  rare  Winckel's 
disease,  there  is  no  other  common  cause  of  jaundice  in  childhood. 
Gallstones  are  practically  unknown,  and  while  the  bile-duct  has  been 
blocked  by  ascaris  lumbricoides  or  some  other  foreign  body,  such 
occurrences  are  so  rare  as  to  hardly  require  consideration. 

Treatment. — This  should  be  directed  on  the  lines  of  any  gastric  and 
intestinal  catarrh.  After  a  period  of  rest  for  the  stomach  and  intestine 
the  diet  should  consist  first  of  thin  cereal  water  and  meat-broth  and 
later  of  milk,  either  plain  or  diluted  with  Vichy  or  carbonated  water. 
When  the  gastric  symptoms  have  subsided  semisolid  food  may  be 
given,  the  fats  and  starches  being  still  restricted.  Junket,  custards, 
meat -jellies,  and  the  like  may  be  given,  and  later  sweetbreads,  scraped 
meat,  chicken,  etc.  For  the  constipation  calomel  and  soda  may  be  given 
in  0.065-0.130  gm.  (1  or  2  grain)  doses  at  night,  with  a  saline  in  the 
morning. 

Apart  from  the  gastric  disturbance  the  patient  suffers  from  the 
presence  of  bile  throughout  the  tissues,  and  efforts  should  be  made  by 
increasing  the  flow  of  urine  to  more  quickly  get  rid  of  the  offending 
material.  For  this  purpose  an  alkaline  diuretic  such  as  the  following 
may  be  of  service: 

9;— Potassii  acetatis, 

Potassii  citratis, 

Potassii  bicarbonatis ad       8.0  gm.  (5ij). 

Aquae q.  s.  ad    120.0  c.c.  (Siv).— M. 

Sig. — 4  c.c.  (one  teaspoonful)  iu  water  t.  i.  d. 

Water  should  be  given  in  abundance. 


JAUNDICE. 

The  jaundice  produced  by  gastroduodenal  catarrh  has  already  been 
described.  The  so-called  physiological  jaundice  of  the  newborn  may 
be  mentioned.  This  is  apparently  dependent  on  the  circulatory  changes 
in  the  liver  brought  about  by  the  changes  in  the  circulation  attendant 
on  birth.  Jaundice  may  also  occur  in  the  newborn  from  congenital 
obliteration  of  the  bile-ducts.     (See  page  60.) 

In  later  childhood  jaundice  from  any  other  cause  than  gastroduodenal 
catarrh  is  extremely  rare.  It  may  be  associated  with  cirrhosis,  or  may  be 
produced  by  blocking  of  the  ducts  by  foreign  bodies,  such  as  ascarides, 
or  by  pressure  from  without  from  tumors,  such  as  masses  of  enlarged, 
lymph  nodes.  Biliary  calculi  are,  as  already  stated,  almost  unknown  in 
childhood.  In  certain  instances  jaundice  is  seen  in  association  with 
the  acute  infectious  diseases,  scarlet  fever,  pneumonia,  or  Weil's  disease.^ 


284  DISEASES  OF   THE  ALIMENTARY   TRACT 

Symptomatology. — The  conjunctivii-  and  skin  are  stained  yellow  or 
yellowish  i^reen.  'I'he  urine  is  dark  yellow  or  brownish,  with  a  yellowish 
foam,  an(l  reaets  to  tests  for  bile  pi<rnients  or  salts.  There  is  loss  of 
appetite,  possibly  nausea  or  vomitiniij.  The  tongue  is  coateil  white. 
The  bowels  are  usually  constipated  with  gray  or  clay-colored  stools, 
the  odor  of  which  is  often  very  offensive.  The  pulse  and  respiration 
are  slow  and  the  temperature  may  be  subnormal.  The  patient  is  usually 
lethargic.  There  may  be  troublesome  itching  of  the  skin.  The  liver 
may  be  enlarged  and  sensitive.  The  course  of  jaundice  depends  entirely 
upon  the  cause. 

Diagnosis. — The  diagnosis  is  made  on  the  pigmentation  of  the  con- 
junctivie,  skin,  and  urine. 

Treatment. — The  treatment  must  be  adapted  to  the  cause. 


CONGESTION  OF  THE  LIVER. 

Acute  congestion  of  the  liver  is  often  spoken  of,  but  of  the  condition 
we  know  practically  nothing.  Chronic  congestion  of  the  liver  is  pro- 
duced by  any  obstruction  to  the  return  of  blood  from  the  liver  to  the 
heart,  such  as  occurs  in  chronic  diseases  of  the  lungs  and  in  cardiac 
failure  from  any  cause. 

The  liver  of  chronic  congestion  is  enlarged,  the  surface  smooth,  the 
cut  section  is  full  of  blood  and  presents  the  characteristic  appearance 
described  as  "nutmeg."  The  consistency  of  the  liver  may  be  increased 
by  the  presence  of  more  or  less  cirrhosis  in  these  cases. 

Symptomatology. — The  symptoms  are  limited  to  enlargement  of  the 
liver  with  possibly  some  tenderness  of  the  edge. 

Treatment. — This  must  be  directed  to  the  cause,  which,  as  is  stated 
above,  is  in  most  instances  the  heart. 

FATTY  LIVER. 

In  this  condition  the  liver  cells  are  infiltrated  with  fat.  The  change 
is  usually  more  or  less  general  throughout  the  organ.  In  the  individual 
cells  the  amount  of  fat  varies;  it  may  completely  occupy  the  cell  body 
or  be  limited  to  minute  droplets  within  it.  A  certain  degree  of  fatty 
infiltration  is  found  in  nearly  all  well-nourished  infants.  It  is  more 
marked  in  children  that  have  suffered  from  diarrheal  diseases  or 
tuberculosis,  but  it  is  certainly  not  observed  to  any  unusual  extent  in 
marasmus,  as  is  so  often  stated  in  text-books.  It  may  be  foimd  to  be 
the  explanation  of  the  enlarged  liver  in  rickets,  or  syphilis.  It  is  not 
infrequently  met  with  after  the  acute  infectious  diseases,  but  it  is  very 
doubtful  whether  the  infectious  disease  has  any  relation  to  the  condition 
of  the  liver,  beyond  that  of  having  caused  death  and  thus  brought  the 
body  to  examination. 

Pathology. — The  liver  is  large,  the  surface  is  smooth,  paler  than  normal, 
or  reddish  yellow  or  distinctly  yellow.     The  section  has  the  same  color, 


DISEASES  OF   THE  LIVER  285 

and  a  warmed  knife  drawn  over  it  will  be  smeared  with  oil.  Micro- 
scopically the  cell  bodies  are  found  more  or  less  replaced  by  fat  droplets. 

Symptomatology. — Fatty  infiltration  is  the  explanation  of  99  per  cent, 
of  the  so-called  enlarged  livers  met  with  in  infancy  and  childhood.  As 
already  stated,  a  certain  amount  of  fatty  infiltration  seems  to  be  normal, 
and  it  is  likewise  normal  for  the  liver  to  be  palpable  during  infancy 
and  at  least  the  early  years  of  childhood.  At  this  time  a  liver  that  is 
normal  may  be  felt  a  finger's  breadth  below  the  free  border  of  the  ribs. 
Rachitic  changes  in  the  thorax  often  cause  a  larger  surface  of  the  liver 
to  be  exposed  to  palpation.  A  liver  that  reaches  the  level  of  the  umbilicus 
in  a  child  may  be  said  to  be  enlarged,  but  if  the  fact  were  appreciated 
that  such  increase  in  size  was  nearly  always  produced  by  simple  fatty 
infiltration  of  the  liver,  there  would  be  fewer  mistaken  diagnoses  of 
cirrhosis,  etc.  The  edge  of  the  fatty  liver  feels  normal;  its  consistency, 
as  determined  by  palpation,  is  normal.  There  are  no  other  symptoms 
whatever. 

Treatment. — Treatment  must  be  limited  to  that  of  the  underlying 
condition.  If  there  is  no  other  disease  present  one  may  be  quite  sure 
that  with  increase  in  age  the  enlargement  of  the  liver  will  disappear. 


AMYLOID  LIVER. 

In  childhood  amyloid  degeneration  of  the  liver  is  most  often  seen  as 
a  sequel  to  chronic  suppuration  in  Pott's  disease  or  tuberculous  osteitis 
of  other  parts;  it  may  also  follow  syphilis,  or  chronic  empyema,  or 
tuberculosis  of  the  lungs. 

The  pathogenesis  of  the  condition  is  the  same  as  in  adult  life:  the 
formation  of  a  peculiar  nitrogenous  substance,  belonging  to  the  class  of 
albumins,  which  is  deposited  in  the  various  tissues,  especially  in  the 
walls  of  the  bloodvessels. 

Pathology. — The  amyloid  liver  is  usually  very  large  and  very  heavy, 
pale  gray  or  grayish  red  in  color,  and  very  tough.  The  cut  surface 
has  a  peculiar  translucent,  glassy  appearance,  and  if  a  little  tincture  of 
iodine  be  poured  over  it  the  amyloid  parts  are  stained  a  deep  mahogany 
brown.  Microscopically  the  degenerated  cells  are  found  especially  in 
the  walls  of  the  smaller  arteries,  but  also  in  the  parenchyma.  The  cells 
have  a  peculiar,  homogeneous,  glassy  appearance,  and  the  nuclei  may 
be  lost.  The  liver  is  never  affected  alone.  Similar  changes  are  found 
in  the  spleen,  and  it  may  be  in  the  kidney,  the  intestines,  the  heart,  and 
bloodvessels  generally. 

Symptomatology. — It  can  only  be  said  that  the  organ  is  notably 
enlarged,  hard,  and  smooth ;  the  edge  is  sharp.  One  cannot  distinguish 
by  palpation  the  amyloid  liver  from  a  fatty  one.  There  are  no  symp- 
toms dependent  on  the  enlarged  liver  in  either  case,  but  in  amyloid 
degeneration  we  have  the  symptoms  produced  by  the  underlying  con- 
dition and  the  widespread  character  of  the  process. 

The  children  are  usually  suffering  from  prolonged  suppuration,  with 


2S6  DISKASJiS  OF    THE   ALIM F.STARY    TRACT 

fever.  Tlicv  are  emaciated,  the  skin  is  reniarkahly  pak^  and  translucent, 
the  l)h>e  veins  stanthng  out  prominently  everywhere.  The  spleen  is 
enlarged,  hard,  and  with  a  sharp  edge,  like  the  liver.  The  urine  usually 
shows  a  large  amount  of  albumin  and  caats,  and  there  may  be  a  general 
tlro[)sy. 

The  condition  is  practically  alw  ays  fatal.  Recovery  has  been  reported 
to  follow  the  excision  of  a  suppurating  joint,  but  it  must  be  very  rare. 
There  may  be  periods  of  temporary  im})rovement,  l)ut  the  progress  is 
usually  steadily  downward. 

Diagnosis. — The  diagnosis  is  founded  on  the  presence  of  an  exciting 
cause,  c.  (f.,  sy])hilis  or  su{)})uration,  on  the  coincident  and  similar  enlarge- 
ment of  the  spleen,  both  liver  and  spleen  being  notably  enlarged,  hard, 
and  with  sharp  edges,  and  usually  upon  the  presence  of  large  amounts 
of  albumin  with  casts  in  the  urine. 

Treatment. — In  syphilitic  cases  mercury  in  such  preparation  as  gray 
powder  and  large  doses  of  iodide  of  j)otash  should  be  given.  In  other 
cases  the  treatment  nmst  be  directed  to  the  primary  disease. 


CIRRHOSIS  OF  THE  LIVER. 

Cirrhosis  of  the  liver  in  childhood  is  often  spoken  of,  but  very  rarely 
seen.  Morse  says  that  it  occurs  once  in  20,000  hospital  cases.  Hatfield, 
in  1890,  collected  156  cases  and  Musser,  in  1899,  129  more,  from  liter- 
ature. In  more  than  a  thousand  autopsies  at  the  Foundling  Hospital, 
New  York,  I  saw  but  one  cirrhotic  liver. 

Etiology. — Congenital  syphilis  is  the  most  common  cause.  Alcohol 
is  responsible  for  from  10  to  25  per  cent,  of  the  cases.  Very  small 
amounts  of  alcohol,  if  taken  regularly,  may  produce  cirrhosis  in  children. 
Abnormal  fermentation  or  decomposition  in  the  intestine  seems  to  be 
a  more  important  factor  in  childhood  than  in  adult  life.  Cirrhosis  of 
the  liver  may  be  dependent  upon  chronic  venous  congestion  produced 
by  tuberculosis,  adherent  pericardium,  or  ac(|uired  heart  disease. 

(ihose  and  others  have  reported  many  hundreds  of  cases  of  cirrhosis 
of  the  liver  in  children  in  India,  the  etiologv  of  which  is  obscure.  Con- 
genital obstruction  of  the  bile-ducts  may  cause  cirrhosis  very  early  in 
life. 

Pathology. — This  does  not  differ  from  that  observed  in  adult  life. 
The  liver  is  more  often  enlarged  than  small.  The  distribution  of  the 
connective  tissue  varies  considerably.  It  may  be  al)out  the  lobules,  or 
along  the  bile-ducts,  in  patches,  or  in  irregular  strands.  Atrophic 
changes  in  the  cells  are  not  marked. 

Symptomatology. — There  are  no  symptoms  peculiar  to  childhood. 
The  early  manifestations  consist  in  disturbances  of  digestion.  Later 
there  is  ascites  with  enlargement  of  the  spleen,  and  of  the  superficial 
veins  of  the  abdomen.  Jaundice,  if  present,  is  slight.  There  may  be 
hemorrhages  from  the  nose,  stomach,  or  intestines.  The  bowels  may 
be  constipated,  but  diarrhea  is  more  common  than  in  adult  life. 


INTUSSUSCEPTION  287 

The  course  of  cirrhosis  in  childhood  is  usually  rapid,  the  children 
dying,  as  a  rule,  in  a  few  months  after  the  appearance  of  ascites.  There 
may,  however,  be  periods  of  improvement. 

A  number  of  cases  of  the  hypertrophic  cirrhosis  of  Hanot  have  been 
described  in  children.  The  affection  is  very  chronic,  lasting  several 
years.  The  liver  is  enlarged  and  hard,  but  smooth.  There  may  be  fever 
at  times.  There  are  attacks  of  pain  referred  to  the  liver.  Jaundice  is 
common  and  often  deep.  The  bowels  are  constipated  but  the  stools  are 
not  clay-colored.  The  urine  may  show  bile.  There  is  no  ascites  and  no 
sign  of  obstruction  to  the  portal  circulation.  The  patients  often  die  of 
malignant  jaundice. 

Prognosis. — Except  in  the  syphilitic  form  this  is  always  bad.  Life 
may  be  prolonged  by  treatment,  but  the  disease  is  incurable  and  the 
end  sure. 

Treatment. — This  must  be  conducted  on  the  lines  of  cirrhosis  in 
adult  life.  A  milk  diet  is  generally  best.  In  the  syphilitic  cases  mercury 
internally  and  mercurial  inunctions  with  large  doses  of  the  iodides  must 
be  given;  and  in  any  doubtful  case  this  treatment  should  receive  trial. 

If  the  ascites  is  considerable,  it  is  best  relieved  by  paracentesis  and 
the  operation  should  be  repeated  as  often  as  the  fluid  reaccumulates. 
Weir's  operation  of  stitching  the  omentum  so  as  to  establish  a  collateral 
circulation,  as  has  been  done  in  adults,  might  be  tried  in  these  cases. 

Rare  Affections  of  the  Liver. — Acute  yellow  atrophy  has  been 
observed  during  childhood  and  likewise  abscess  of  the  liver,  echinococcus 
cysts,  and  even  malignant  tumors,  but  these  conditions  are  so  rare,  and 
the  symptoms,  so  far  as  known,  so  much  like  those  of  adult  life,  as  to 
render  their  separate  consideration  inadvisable. 


INTUSSUSCEPTION. 

In  intussusception  obstruction  of  the  bowels  is  produced  by  the 
invagination  or  ensheathing  of  one  segment  of  the  bowel  in  another, 
just  as  one  part  of  a  telescope  slides  into  the  next.  Intussusception  is 
the  one  form  of  intestinal  obstruction  common  in  infancy.  Obstruction 
from  Meckel's  diverticulum,  from  bands  or  adhesions,  occurs  but 
seldom. 

Etiology. — The  affection  is  found  especially  in  male  children,  the 
ratio  being  about  two  to  one.  It  is  very  rarely  seen  under  the  age  of 
four  months,  while  the  period  from  the  fourth  to  the  twelfth  month  is 
that  of  greatest  incidence.  Cases  are  less  frequent  in  the  second  year 
and  after  infancy  are  quite  uncommon. 

An  intussusception  being  produced  by  disordered  peristalsis  in  the 
bowel,  any  disturbance  of  the  bowel  associated  with  increased  peristalsis, 
as  diarrhea,  tumor  of  the  intestine,  stricture  or  polypoid  growths,  the 
presence  in  the  bowel  of  irritating  food,  may  be  regarded  as  a  predisposing 
factor.  The  affection  appears  in  children  suffering  from  such  diseases 
and  also  in  those  apparently  in  perfect  health.     In  the  week  following 


288 


DISEASES  OF    THE   ALIMEXTARY    TRACT 


Christmas,  1902,  seven  casv\s  of  intussusception  were  admitted  to  the 
London  Hospital.  Intussus(ri)tion  is  rare,  however,  among  infants  or 
children  sutferin<:r  from  the  acute  diarrheal  diseases  of  summer. 

Certain  anatomical  factors  undoubtedly  play  a  part  in  the  incidence 
of  this  disease,  especially  the  relative  thinness  of  the  walls  of  the  intestine 
during  infancy,  and  the  much  greater  looseness  of  both  mesentery  and 
mesocolon.  The  latter  especially  is  notably  long,  permitting  a  latitude 
of  motion  quite  impossible  later  in  life. 


Fig.  63 


An  ileocolic  intussusception:  a,  small  intestine  above ;  6,  colon  below;  c,  apex  of  intussusception 
swollen,  congested,  and  covered  with  membranous  exudate  ;  d,  appendix. 


Pathology. — An  intussusception  may  involve  only  the  small  or  large 
intestine,  and  is  then  known  as  ileal  or  colic,  according  to  the  part 
affected  (Fig.  53).  In  most  cases,  however,  the  intu.ssusception  involves 
both  ileum  and  colon.  The  conditions  can  best  be  illustrated  bv  diagram 
(Fig.  54). 

The  outer  or  ensheathing  layer  A  is  known  as  the  intussuscipiens;  the 
inner  or  ensheathed  layer  B  is  the  intussusceptum.    The  apex  of  the 


IXTUSSUSCEPTION  289 

intiissusceptum  is  at  D,  the  neck  at  C.  In  most  cases  in  the  beginning 
the  outer  sheath  is  colon,  the  intussusceptmn  is  small  intestine.  The 
apex  of  the  intussiisceptum  is  often  the  ileocecal  valve,  and  in  such  case 
the  valve  remains  the  apex  of  the  intussusceptum,  the  increase  coming 
from  infolding  first  of  the  cecum  and  later  of  the  colon.  In  other  cases 
the  ileum  slips  through  the  valve,  which  then  forms  the  neck  of  the 
intussuscipieiis  and  the  increase  will  then  be  made  by  more  and  more 
of  the  ileum  passing  through  the  valve;  the  neck  remains  constant, 
while  the  apex  continually  changes.  Numerous  cases  are  on  record  in 
which  an  iuvaginated  ^Meckel's  diverticulum  or  appendix  was  found  at 
the  apex  of  the  intussusception.  The  intussusceptum  may  be  only  an 
inch  or  two  or  several  feet  in  length.  Owing  to  the  fact  that  the  mesen- 
tery is  carried  in  vdih  the  intussusceptum,  the  intussusception  is  often 
curved  in  upon  itself  toward  the  mesenteric  attachment.  In  most 
clinical  cases  intussusceptions  are  produced  by  the  telescoping  of  an 
upper  into  a  lower  segment  of  the  gut;  in  a  certain  number  of  cases  the 
process  is  reversed  and  a  lower  portion  is  invaginated  into  an  upper. 
Intussusceptions  are  nearly  always  single,  but  double  and  even  triple 
intussusceptions  have  been  recorded.  Multiple  intussusceptions  are 
very  rarely  seen  clinically,  but  are  a  common  occurrence  in  the  post- 

FiG.  54 


DiagTammatic  drawing  of  an  intussusception  :    A,  intussuscipiens  ;   B,  intussusceptum  ; 
C,  neck  ;  D,  apes  of  intussusceptmn. 

mortem  room.  It  is  now  well  known  that  intussusception  may  occur 
during  the  final  hours  of  life  without  giving  clinical  symptoms.  These 
agonal  intussusceptions  are  all  in  the  small  intestine,  may  be  very 
numerous,  as  many  as  a  dozen  in  one  case,  and  may  be  either  of  ascend- 
ing or  descending  type,  or,  indeed,  of  both.  There  are  no  pathological 
changes  in  the  intestine  in  these  cases. 

The  pathological  changes  found  in  clinical  cases  vary  with  the  length 
of  time  which  has  elapsed  from  the  formation  of  the  intussusception, 
but  still  more  with  the  amount  of  interference  with  the  lumen  of  the 
bowel  and  the  nutrition  of  the  parts  involved.  The  intussusceptum 
becomes  deeply  engorged  with  blood  and  swollen,  the  enlargement 
being  greatest  at  the  apex,  a  fact  which  accounts  for  the  difficulty  often 
met  with  in  reducing  the  last  few  inches  of  the  intussusceptum.  Follow- 
ing the  swelling  there  may  be  hemorrhage  into  the  tissues  of  the  intus- 
susceptum, which  soon,  unless  the  constriction  is  relieved,  sloughs  off, 
the  separation  occurring  at  the  neck.  Usually  after  an  intussusception 
has  existed  for  two  or  three  days,  there  are  more  or  less  firm  adhesions 
between  the  serous  surfaces  of  the  intussuscipiens  and  intussusceptum. 
These  adhesions  may  develop  very  rapidly,  or  they  may  be  entirely 
absent  after  a  week.  In  chronic  cases  they  constitute  the  greatest 
obstacle  to  reduction.  At  any  time  a  general  peritonitLs  may  be  excited, 
19 


290  DISEASES  OF   THE   MJMEXTAliY    TRACT 

ill  some  cases  apparently  from  infection  through  the  weakened  intestinal 
wall,  in  others  from  perforation  of  the  wall  of  the  gut  at  the  neck. 

Symptomatology. — The  onset  of  intussusception  is  usually  very  sudden 
and  acute.  An  infant  apparently  in  good  health  is  suddenly  seized 
with  severe  alKJominal  pain,  cries  vehemently,  flexes  the  legs  on  the 
alxiomen,  vomits,  and  is  greatly  prostrated.  The  vomiting  continues, 
the  vomitus  being  at  first  ordinary  gastric  contents;  later  it  may  be 
bile-tinged  and  finally  it  is  fecal.  With  the  onset  of  the  attack  the  bowels 
move  once  or  twice,  the  stools  consisting  of  normal  feces.  ^  ery  soon 
there  are  movements  of  blood  and  mucus,  looking  very  much  like 
currant-jelly.  Prostration  is  usually  marked  from  the  beginning.  The 
temptTature  at  the  outset  and  usually  for  several  days  thereafter  is 
normal;  the  respiration  is  normal,  the  pulse  is  rapid  and  feeble.  The 
facies  is  usually  pale  and  anxious.  The  infant  may  take  nourishment 
greedily,  l)ut  only  to  vomit.  The  severe  pains  and  crying  are  repeated 
from  tii7ie  to  time.  The  progress  of  the  case  is  that  of  any  case  of 
intestinal  obstruction,  the  patient  not  looking  very  sick,  but  steadily 
losing  strength  through  successive  days.  The  striking  features  are  the 
vomiting,  which  is  successively  food,  bile,  feces;  the  repeated  attacks  of 
.severe  pain,  with  collapse,  the  passage  of  blood-stained  mucus  from  the 
bowel,  and  finally,  the  presence  of  an  abdominal  tumor.  The  vomiting 
is  regularly  persistent;  it  may  be  projectile.  At  first  the  vomitus  consists 
of  normal  gastric  contents,  later  it  becomes  bilious,  and  still  later  it  may 
l)e  fecal.  Fecal  vomiting  occurs  in  only  15  per  cent,  of  the  cases  in 
infants,  and  is  not  seen  until  tlie  third  or  fourth  day.  When  present, 
it  is  of  considerable  importance  from  the  standpoint  of  diagnosis. 

The  tumor  felt  is  formed  by  the  telescoped  intestine,  and  is,  therefore, 
usually  in  the  line  of  the  colon;  and  as  the  colon  is  foreshortened  by 
the  process  of  intussusception,  the  mass  will  most  often  lie  near  the 
hepatic  flexure  or  in  the  position  of  the  transverse  colon.  The  tumor 
is  round  and  usually  long,  dascribed  as  sausage-shaped.  It  may  be  felt 
to  harden  under  the  hand.  The  position  and  size  of  the  tumor  vary 
from  time  to  time  with  progress  of  the  intussusception.  It  is  possiljle 
for  the  mass  to  be  felt  by  the  rectum,  or  in  extreme  cases  it  presents  at  the 
anus  like  a  prolapse  of  the  rectum.  Not  infrecjuently  no  tumor  can  be 
felt.  The  abdomen  is  usually  soft  and  may  be  retracted,  yet  on  account 
of  pain  and  the  natural  .sensitiveness  of  an  infant  to  any  manipulation 
it  may  be  impossible  to  obtain  a  satisfactory  examination  without  an 
anesthetic.  After  the  first  day  or  two  the  abdomen  becomes  distended 
and  tympanitic.  Relaxation  of  the  rectal  sphincter  has  been  noted  in 
cases  in  which  the  tumor  lay  in  the  rectum  or  sigmoid.  After  the  onset, 
constipation  is  usually  absolute,  neither  gas  nor  feces  being  passed,  but 
this  fact  is  often  overlooked  by  reason  of  the  passage  of  blood  and 
mucus.  The  amount  of  blood  pa.s.sed  is  small,  usually  only  enough  to 
tinge  the  mucus;  in  some  instances  the  blood  is  more  abundant  than 
the  mucus.  There  may  be  frequent  passages  of  small  amounts  of 
blood  and  mucus  every  hour  or  two. 

At  the  onset  the  temperature  is  usually  normal.     After  the  first  day 


INTUSSUSCEPTION  291 

or  two  it  may  show  a  rise  of  one  or  two  degrees,  but  it  is  never  in  the 
early  stages  in  proportion  to  the  prostration  or  collapse.  Late  in  the 
disease  the  temperature  mounts  steadily,  irrespective  of  the  presence 
of  peritonitis.  The  latter  is  comparatively  rare  and  is  usually  limited 
to  the  immediate  neighborhood  of  the  intussusception.  Rupture  of  the 
gut  is  rare  under  any  conditions. 

The  urine  is  usually  scanty  from  the  repeated  vomiting,  but  the 
symptom  is  of  little  value. 

The  course  of  the  disease  in  infants  is  nearly  always  acute.  In  older 
children  the  progress  is  slower,  and  in  some  a  condition  of  chronic 
intussusception  is  developed.  The  affection  may  be  fatal  within  twenty- 
four  hours,  but  most  of  the  cases  are  protracted  for  four  or  five  days. 
The  duration  appears  to  depend  mainly  upon  the  age  and  resistance  of 
the  patient  and  the  site  of  the  obstruction.  As  a  rule,  the  higher  the 
obstruction  the  severer  the  vomiting  and  prostration,  and  the  earlier 
the  exhaustion.  Cases  rarely  last  beyond  a  week,  unless  the  obstruction 
is  only  partial  and  the  condition  of  a  chronic  intussusception  is  developed. 

Spontaneous  reduction  undoubtedly  occurs.  D'Arcy  Power  has 
recently  reported  two  instances  of  spontaneous  reduction.  Treves  and 
others  consider  that  many  of  the  attacks  of  severe  colic  may  be  due  to 
small  intussusceptions  which  resolve  spontaneously  or  under  the  influence 
of  opium.  The  symptoms  of  severe  colic  and  intussusception  are 
certainly  suggestively  similar. 

It  is  possible  that  the  intussusception  may  become  gangrenous, 
slough  off,  and  recovery  occur  spontaneously,  the  outer  and  inner  tubes 
of  the  intussusception  uniting  at  the  neck,  but  in  an  infant  such  a  result 
is  not  to  be  expected.  Snow,  of  Buffalo,  has,  however,  recently  reported 
a  case  in  which  a  seven  months'  child  suffered  from  an  intussusception 
for  sixteen  days,  when  a  piece  of  gangrenous  intestine  six  inches  in 
length  protruded  from  the  rectum,  was  ligated,  and  removed,  recovery 
following.  In  infants  spontaneous  resolution  is  more  probable  than 
recovery  by  this  process.    In  older  children  it  may  be  more  frequent. 

In  the  so-called  chronic  cases,  lasting  several  weeks  or  months,  the 
symptoms  are  not  at  all  regular.  Usually  there  is  an  abdominal  tumor 
which  varies  its  shape  and  position  from  time  to  time.  There  are  attacks 
of  pain  and  prostration,  and  the  condition  of  the  bowels  varies ;  in  some 
cases  there  is  diarrhea,  in  other  cases  alternating  diarrhea  and  consti- 
pation.   The  recognition  of  the  tumor  is  the  important  point. 

Diagnosis. — The  sudden  onset  without  fever,  the  persistent  vomiting, 
the  severe  pain  with  symptoms  of  collapse,  the  passage  of  blood  and 
mucus  without  fecal  matter  or  gas,  and  finally  the  presence  of  a  tumor 
are  the  diagnostic  symptoms.  If  the  possibility  of  intussusception  is 
borne  in  mind  the  diagnosis  is  usually  easy.  The  most  common  error 
is  to  mistake  these  cases  for  ileocolitis  or  dysentery.  In  the  latter 
affection  fever  is  present  from  the  beginning,  usually  in  proportion  to 
the  severity  of  the  attack;  the  vomiting  is  not  so  persistent;  the  stools 
contain  more  or  less  fecal  matter  in  addition  to  blood  and  mucus,  the 
blood  being  usually  of  small  amount ;  the  pain  is  not  so  severe,  and  there 


292  DISIiASES  OF    TIIK   M.IM h'XTAh'Y    TRACT 

is  no  tumor.  '1'Ik"  pivsent'c  of  a  tumor  would  at  once  exclude  this  con- 
dition, but  unfortunately  a  tumor  is  not  always  to  be  felt  in  intussuscep- 
tion. In  over  (iO  j)er  cent,  of  Erdmann's  28  cases  no  tumor  could  be 
felt  in  either  the  abdomen  or  rectum.  The  rectal  examination  should 
never  be  forijjotten. 

\Vithout  tumor  the  symptoms  point  only  to  intestinal  obstruction, 
except  that  the  piussages  of  blood  and  mucus  are  fairly  distinctive; 
and  while  intestinal  obstruction  from  bands,  adhesions,  or  INIeckcd's 
diverticulum  does  occur  in  infancy,  this  conilition  is  exceedin<j;ly  rare 
as  compared  with  intussusception. 

Prognosis. — The  prognosis  is  always  very  grave,  Leichtenstern's 
statistics  showing  a  mortality  of  73  per  cent,  and  Fitz's  09  per  cent, 
'i'he  vounger  the  child  the  graver  the  j)rospect;  the  earlier  the  diagnosis 
is  made  and  proper  treatment  instituted  the  better  the  prognosis. 
Spontaneous  reduction  is  too  rare  to  be  depended  upon.  If  the  invagi- 
nation can  be  reduced  by  inflation  with  air  or  injections  of  water  the 
case  is  hopeful,  although  in  these  cases  the  condition  occasionally  recurs, 
probably  from  failure  to  reduce  the  last  few  inches  of  the  swoIUmi  intus- 
susceptum.  After  the  second  or  third  day  reduction  by  these  methods 
is  rather  problematical.  Within  the  last  few  years  great  progress  has 
been  made  by  treating  these  cases  promptly  by  laparotomy.  The 
earlier  the  operation  the  better  the  prospect  of  successful  outcome. 
The  chance  of  recovery  by  the  sloughing  of  the  intussusceptum  and 
spontaneous  cure  is  too  small  to  be  considered  in  infants. 

In  chronic  intussusception  also  the  prospect  is  very  grave.  Here 
operation  is  essential,  yet  adhesions  will  usually  have  formed  so  as  to 
prevent  reduction  and  necessitate  a  resection — always  a  difficult  and 
dangerous  operation  in  a  child. 

Treatment. — Once  the  diagnosis  is  made,  the  essential  thing  is  the 
reiluction  of  the  intussusception,  and  the  more  promptly  this  is  attempted 
the  greater  the  prospect  of  success.  As  preliminary  measures,  all  feeding 
should  be  stopped,  the  stomach  may  be  washed  out  to  check  the  vomit- 
ing, and  morphine  given  hypodermically  to  relieve  pain  and  cjuiet 
peristalsis,  O.OOOG  gm.  (gr.  yrir)  ^^  ^  ehild  a  year  old.  For  the  reduction  of 
the  intussusception  conservative  opinion  still  advises  the  use  of  inflation 
with  atmospheric  air  or  injections  of  large  (juantities  of  water;  with 
either,  abdominal  taxis  should  be  em])loyed.  In  any  case  inflation  or 
injection  is  allowable  as  a  preliminary  treatment  if  the  method  does  not 
lead  to  procrastination  in  the  performance  of  laparotomy.  The  pro- 
cedures are  as  follows: 

Inflation. — The  child  should  be  placed  upon  its  back  on  an  inclined 
plane,  head  downward.  The  air  is  best  injected  through  a  large  catheter 
(20  French),  attached  to  an  ordinary  foot-bellows.  There  is  no  exact 
standard  for  the  measurement  of  the  force  that  is  permissible.  The  air 
should  be  slowly  injected ;  the  tumor,  if  present,  should  be  gently  manipu- 
lated in  the  direction  in  which  reduction  should  occur.  Danger  of 
injury  to  the  intestine  by  these  manipulations  must  be  admitted,  though 
rupture  has  been  very  rarely  caused. 


INTUSSUSCEPTION  293 

Instead  of  air,  Senn  advises  hydrogen  gas  and  others  carbon  dioxide, 
but  as  the  essential  thing  is  promptness  air  is  usually  to  be  preferred. 

Reduction  is  often  accompanied  by  a  gurgling  sound  and  a  sudden 
disappearance  of  the  tumor  under  the  fingers. 

Injections  of  water  are  made  with  the  child  in  the  position  described. 
A  fountain  syringe  at  a  height  of  four  or  five  feet  is  generally  used. 
The  water  should  be  at  a  temperature  of  100°  to  105°  F.  Milk,  saline 
solution,  or  gruel  are  advised  as  being  less  irritating,  but  it  is  best  to  use 
water.  The  injections  are  made  through  a  large  catheter  (20  or  25 
French)  and  are  to  be  directed  as  nearly  as  may  be  on  the  apex  of 
the  tumor.  The  height  of  the  flow  may  be  increased  to  six  or  even 
eight  feet,  but  the  danger  of  rupture  is  increased  by  such  procedure, 
and  a  pressure  beyond  four  or  five  feet  should  not  be  employed  in 
cases  of  many  days'  standing.  From  one  to  six  quarts  of  fluid  may 
be  used,  as  much  as  possible  being  retained  by  pressing  the  buttocks 
together.    Taxis  should  be  applied  as  in  the  use  of  inflation. 

If  either  of  these  methods  results  in  the  reduction  of  the  intussuscep- 
tion, the  patient  should  be  kept  absolutely  quiet,  feeding  for  several 
days  kept  at  a  minimum,  and  morphine  or  opium  given  to  quiet  peris- 
talsis and  promote  rest.  If  symptoms  return,  injection  or  inflation  may 
be  tried  a  second  time ;  but  with  a  second  return  of  symptoms  after  relief, 
or  failure  to  relieve  the  condition,  laparotomy  should  be  immediately 
performed. 

Laparotomy  is  now  advocated  by  surgeons  as  the  proper  treatment  for 
all  cases.  Emphasis  is  laid  upon  the  brilliant  results  of  immediate 
operation.  It  is  now  generally  admitted  that  infants  bear  laparotomy 
much  better  than  was  formerly  believed.  Statistics  show  that  operations 
on  the  first  or  second  day  are  successful  in  about  50  per  cent,  of  the 
cases,  and  individual  operators  report  better  results  in  limited  numbers 
of  cases.  The  essential  steps  in  the  operations  are  the  opening  of  the 
abdomen  over  the  site  of  the  tumor,  if  one  be  present,  and  the  reduc- 
tion of  the  intussusception.  This  is  sometimes  combined  with  an  efi^ort 
to  shorten  the  mesentery  in  the  hope  of  rendering  recurrence  more 
difficult.  Reduction  may  be  impossible  from  the  presence  of  adhesions, 
from  too  great  swelling  of  the  intussusceptum,  or  may  be  inadvisable  by 
reason  of  the  condition  of  the  gut.  A  resection  will  in  that  case  be 
necessary.  Conditions  calling  for  such  complicated  operations  greatly 
lessen  the  chances  of  recovery. 

In  chronic  intussusception  in  older  children,  palliative  treatment  may 
be  attempted,  in  the  hope  that  the  intussusceptum  may  slough  ofl'  and  be 
discharged  with  resulting  natural  cure.  Even  if  this  occur,  there  will 
be  later  difficulty  from  cicatricial  contracture  of  the  scar  and  adhesions. 

Operation  in  these  cases  is  difficult  and  dangerous,  because  the  con- 
ditions usually  forbid  reduction  and  necessitate  resection  of  the  intes- 
tine. 


294  DISEASES  OF   THE   ALIMENTARY   TRACT 


APPENDICITIS. 

Under  the  caption  of  appendicitis  are  now  included  all  the  inflam- 
matory processes  involving  the  appendix  and  cecum,  since  we  are 
satisfied  that  in  practically  all  ca.ses  the  appendix  is  the  part  primarily 
involved. 

Etiology. — Appendicitis  is  rare  in  early  childhood  and  seldom  seen  in 
infancy.  In  the  course  of  more  than  1000  autopsies  on  infants  and 
children  under  the  age  of  five  years  at  the  New  York  Foundling  Hos- 
pital, evidence  of  old  inflammation  in  the  aj)pendix  was  found  but 
twice.  There  is  a  curious  predisposition  on  the  part  of  males,,  boys 
being  the  more  affected  in  the  proportion  of  two  to  one. 

Some  cause  of  local  irritation  may  be  found  in  the  appendix,  a  small 
mass  of  iiardened  feces,  a  seed  or  fruit-stone,  in  some  instances  pins,  or 
other  foreign  substance. 

Blows  or  injuries  to  the  abdomen  are  responsible  for  the  production 
of  some  few  cases,  probably  by  lighting  up  some  old  catarrhal  or  inflam- 
matory process. 

Undoubtedly  bacteria  play  a  part  in  the  process,  especially  the  colon 
bacillus.  Most  cases  must  be  explained  upon  the  basis  of  a  })riinary 
irritation  by  a  catarrhal  condition  or  foreign  body  in  an  almost  closed 
sac,  with  the  secondary  invasion  of  pathogenic  micro-organisms.  The 
aft'ection  is  seen  in  close  association  with  acute  tonsillitis.  Some  observers 
hold  that  appendicitis  belongs  in  the  category  of  acute  infectious  diseases, 
a  view  for  which  there  is  certainly  some  ground. 

Pathology. — So  far  as  known,  the  pathology  of  appendicitis  in  children 
does  not  differ  essentially  from  the  conditions  found  in  adult  life,  except 
that  the  position  of  the  appendix  is  more  varial)lc  in  the  earlier  y(>ars. 
I  have  seen  the  appendix  lying  deep  in  the  pelvis  with  an  abscess  formed 
from  it,  approaching  the  rectum;  in  other  instances  touching  the  neck 
of  the  gall-bladder,  and  in  still  others  lying  well  to  the  left  of  the 
umbilicus. 

1.  Catarrhal  Appendicitis. — In  this  condition  there  is  an  acute 
catarrhal  inflammation  of  the  mucous  membrane  of  the  appendix.  The 
tube  is  enlarged,  its  walls  slightly  infiltrated,  the  cavity  filled  and  possibly 
distended  with  mucus  or  mucopus.  In  some  instances  the  lumen  of  the 
appendix  becomes  obliterated  at  or  near  its  opening  into  the  cecum, 
and  escape  of  its  contents  being  prevented  a  cyst  is  formed  which  may 
rupture  into  the  peritoneal  cavity. 

2.  Ulcerative  or  Perforating  Appendicitis. — In  this  form  in  addi- 
tion to  the  changes  present  in  the  catarrhal  appendicitis  we  find  an 
ulcerative  lesion  of  the  walls..  The  ulceration  may  destroy  only  the 
mucous  membrane  or  may  perforate  all  the  walls  of  the  tube;  the 
perforation  is  usually  near  the  tip  of  the  appendix  and  is  caused 
by  a  twisting  or  obliteration  of  the  bloodvessel  supplying  the  appendix. 

3.  Gancjrenous  Appendicitis. — In  a  certain  number  of  cases,  appar- 
ently by  reason  of  interference  with  the  circulation  of  the  appendix, 


APPENDICITIS 


295 


Fig.  55 


produced  by  the  pathological  process  and  the  invasion  of  virulent 
bacteria,  the  whole  appendix  becomes  black  and  necrotic  and  sloughs 
off;  in  other  instances  only  a  part  of  the  organ  becomes  gangren- 
ous. 

With  all  severe  cases  of  appendicitis  there  is  more  or  less  acute  peri- 
tonitis. In  the  simpler  cases  we  find  the  peritoneum  of  the  appendix 
and  surrounding  parts  congested  and  coated  with  a  little  fresh  fibrin, 
and  there  may  be  some  delicate  adhesions.  In  other  instances  even 
without  perforation  there  may  be  a  general  acute  plastic  peritonitis. 
In  cases  of  ulcerative  or  gangrenous 
appendicitis  we  may  find  a  localized 
peritonitis  before  the  perforation; 
after  perforation  there  will  be 
either  a  localized  abscess  or  a  gen- 
eral suppurative  peritonitis.  The 
factors  determining  the  fate  of  the 
peritoneum  in  these  cases  seem  to 
be  the  position  of  the  appendix, 
which  sometimes  favors  and  some- 
times prevents  the  formation  of  ad- 
hesions ;  the  resistance  of  the  tissues, 
and  the  virulence  of  the  infecting 
organisms. 

In  cases  of  old  appendicitis  we 
find  the  appendix  bound  down  by 
adhesions,  thickened,  and  probably 
containing  pus.  In  some  instances 
we  find  small  abscess  cavities 
closely  walled  off  by  firm  adhe- 
sions. 

Symptomatology.  Catarrhal  Ap- 
pendicitis.— A  mild  attack  of  ap- 
pendicitis in  a  child  is  shown  by 
a  slight  rise  of  temperature  (100° 
to  101°  F.),  vomiting,  constipation, 
pain  in  the  right  iliac  fossa,  and 
tenderness  over  the  appendix,  usu- 
ally at  IMcBurney's  point  (Fig.  55). 
In  many  cases  it  may  be  difficult 
to  satisfy  one's  self  as  to  the  diag- 
nosis, and  the  presence  of  an  ap- 
pendicitis can  only  be  suspected. 
Doubtless,  also,  many  of  these  mild 
attacks  pass  unheeded  by  children. 
iVfter  a  day  or  two  of  fever  and 
pain  the  trouble  regularly  subsides, 

but  the  patient  is  very  "likely  to  have  recurrent  attacks.  During  the 
attack  there    mav  be    only  a  sense  of  resistance  on  palpation   of  the 


Photograpli  showing  McBumey's  point.  The 
dot  on  the  right  side  of  the  ahdomen  midway 
between  the  umbilicus  and  the  anterosuperior 
spine  of  the  ilium  represents  the  location  of  the 
point. 


29G  DISEASES  OF   THE  ALI.}fENTARy   TRACT 

appendical  region,  or  there  may  be  a  definite  mass.  With  the  sub- 
si(UMK'e  of  the  inHanmiation  these  local  signs  entirely  (lisaj)j)ear. 

rU-cmiive  or  Pcrjoraiincj  Apprndirlli.s. — The  onset  in  these  eases 
presents  great  variations.  In  a  typical  ease  the  disease  begins  with  a 
rise  of  temperature — 102°  to  103°  F. — rarely  with  a  chill,  accompanied 
by  nausea,  vomiting,  constipation,  and  more  or  less  severe  abdominal 
pain.  The  })ain  in  the  beginning  is  diffuse,  or  is  referrcnl  to  the  umbilicus. 
After  twenty-four  or  forty-eight  hours  it  is  localized  over  the  appendix. 
The  bowels  are  usually  constipated,  but  diarrhea  may  occur.  In  other 
instances  the  onset  of  the  disease  is  gradual,  the  temperature  is  sligiit, 
the  constitutional  disturbance  mild,  and  the  evidences  of  appendicitis 
are  found  on  tiie  physical  examination,  a  tumor  or  mass  being  found  in 
the  right  iliac  fossa  with  some  tenderness  over  the  aj^pendix. 

In  still  other  cases  the  first  evidence  of  the  onset  of  the  appendicitis 
is  the  development  of  an  acute  general  peritonitis,  with  its  characteristic 
vomiting,  rapid,  small,  hard  pulse,  drawn  facies,  rigid,  tender  abdomen, 
and  great  prostration. 

On  the  second  or  third  day  of  an  ulcerative  appendicitis,  begiiming 
either  insidiously  or  with  the  classic  symptoms,  the  c-ondition  is  usually 
characteristic.  The  patient  lies  on  the  back  with  the  knees  drawn  up 
and  the  facies  is  anxious  and  distressed.  The  tempei-ature  is  102°  to 
104°  F. ;  the  pulse  is  rapid,  but  otherwise  normal;  the  respiration  is 
normal  or  is  rather  shallow  and  suppressed,  the  abdomen  being  held 
immobile.  The  tongue  is  coated;  there  is  nausea  and  possibly  vomiting, 
either  of  food  or  bilious  material,  and  the  bowels  are  fpiite  constipated. 
On  examination  we  find  the  abdomen  held  almost  immobile  in  respira- 
tion; it  is  usually  distended  and  tympanitic;  there  may  be  a  prominence 
of  the  right  side.  On  palpation  there  is  a  distinct  resistance  in  the 
right  iliac  fossa,  or  there  may  be  a  definite  tumor  or  mass  in  the  fossa. 
From  this  point  the  further  course  depends  upon  the  progress  of  the 
local  process.  It  may  resolve;  it  may  go  on  to  the  formation  of  an 
abscess;  it  may  at  any  time  produce  an  acute  general  peritonitis. 

Resolution. — When  this  occurs  a  plastic  peritonitis  shuts  off  the  inflam- 
matory process  in  the  appendix  and  the  inflammation  subsides.  The 
temperature  gradually  falls,  the  constitutional  symptoms  subside,  the 
local  induration  or  tumor  diminishes,  and  at  the  end  of  a  week  or  ten 
days  the  patient  is  convalescent.  There  may  be  some  induration  in 
the  appendical  region  for  weeks  thereafter. 

Abscess  Formation. — In  these  cases  the  appendix  ruptures  or  perfo- 
rates, but  having  been  previously  walled  off  ])y  a  plastic  peritonitis,  only 
a  localized  abscess  results.  The  temperature  usually  remains  elevated, 
but  may  fall,  the  pulse  in  either  case  continues  rapid,  the  nausea  and 
vomiting  continue,  and  the  constipation  persists,  while  the  local  signs 
increase.  The  pain  may  increase,  but  is  often  surprisingly  small  after 
the  abscess  has  formed.  The  mass  in  the  iliac  fossa  continues  to 
increase  in  size,  remains  tender,  and  after  a  day  or  two  fluctuation  may 
be  determined.  With  the  formation  of  the  abscess  there  may  be  pro- 
fuse persjiiration.     The   abscess    once  formed  is  now  regularly  recog- 


APPENDICITIS  297 

nized  and  evacuated.  In  neglected  cases  it  is  possible  for  such  an 
abscess  to  rupture  externally,  either  in  the  flank  or  in  the  groin.  ]More 
often  the  patient  dies  of  sepsis  or  of  an  acute  general  peritonitis  from 
rupture  of  the  abscess  into  the  peritoneum. 

Acute  Gejieral  Peritonitis. — This  may  arise  either  from  rupture  of  a 
previously  localized  abscess,  or  from  extension  of  the  inflammatorv 
process.    The  symptoms  are  characteristic  of  the  condition.    (See  p.  302.) 

The  course  of  an  appendicitis,  therefore,  depends  upon  the  severitv 
of  the  pathological  process  and  the  local  conditions  favoring  or  hindering 
the  localization  of  the  inflammation  by  the  formation  of  adhesions. 
The  mild  catarrhal  cases  run  their  course  in  a  few  days.  The  severe 
cases  with  localized  peritonitis  may  resolve  within  a  week  or  ten  davs. 
The  cases  with  abscess  formation  usually  reach  the  climax  and  are 
opened  within  from  five  to  seven  days;  thereafter  the  symptoms  subside 
and  the  patients  convalesce.  The  abscess  may  be  slow  in  forming  and 
operation  may  be  delayed,  recovery  being  correspondingly  slow 

The  development  of  an  acute  general  peritonitis  is  regularly  a  fatal 
complication,  most  of  the  patients  dying  within  a  few  days. 

Diagnosis. — The  diagnosis  of  appendicitis  is,  as  a  rule,  not  difficult. 
The  mild  cases  may  be  easily  mistaken  for  attacks  of  colic  or  indigestion, 
if  careful  examination  of  the  abdomen  is  not  made.  Tenderness  in  the 
right  iliac  fossa,  rigidity  of  the  right  rectus,  or  tumor  in  the  fossa  should 
cause  one  to  suspect  appendicitis,  and  subsecjuent  observation  should 
determine  the  question.  From  intestinal  obstruction  or  intussusception 
appendicitis  differs  in  the  presence  of  fever  from  the  beginning;  in  less 
persistent  vomiting,  which  is  never  fecal;  in  more  continuous  pain  and 
greater  tenderness,  and  more  marked  rigidity  of  the  abdominal  wall; 
in  the  shape,  location,  and  feeling  of  the  tumor;  and  in  the  absence  of 
the  passages  of  mucus  and  blood  which  are  characteristic  of  intus- 
susception. The  mass  or  tumor  in  intussusception  is  round  or  elongated, 
is  in  the  course  of  the  bowel,  may  be  movable,  and  often  from  time  to 
time  changes  position;  it  is  more  likely  to  be  in  the  position  of  the 
transverse  or  descending  colon  than  in  the  right  iliac  fossa;  it  may 
sometimes  be  felt  to  contract  and  harden  under  the  fingers.  The 
sensation  obtained  in  palpating  a  case  of  appendicitis  is  more  often  an 
indefinite  resistance.  If  a  tumor  is  felt,  it  lies  nearlv  alwavs  in  the  right 
iliac  fossa,  is  fixed  in  position,  and  only  the  surface  projecting  toward 
the  peritoneal  cavity  can  be  palpated.  Rectal  examination  may  be 
decisive  between   the  two  conditions. 

The  possibility  of  mistaking  a  right-side  pneumonia  for  an  acute 
appendicitis  is  to  be  remembered  as  of  great  importance.  In  certain 
cases  of  such  pneumonia,  probably  cases  complicated  by  diaphragmatic 
pleurisy,  there  is  complaint  of  pain  in  the  appendical  region,  with  tender- 
ness to  palpation  and  rigidity  of  the  right  rectus,  a  group  of  symptoms 
very  suggestive  of  appendicitis. 

It  may  be  twenty-four  hours  or  longer  before  the  development  of 
characteristic  physical  signs  makes  the  diagnosis  clear.  In  pneumonia 
we  look  for  more  rapid  pulse  and  respiration  and  a  disturbance  of  the 


298  DISEASES  OF   THE  ALIMENTARY    TRACT 

pulse-respiration  ratio,  some  nioveineiit  of  the  ahe  nasi,  cough,  even  if 
slight,  some  limitation  of  motion  on  the  atteeted  side,  and  a  more  con- 
tinued and  iiigher  fever  than  belongs  to  a  beginning  appendicitis. 

Careful  and  thorough  observation  should  suffice  to  detect  the  char- 
acteristic physical  signs,  either  of  a  ])neumonia  or  of  the  appendicitis, 
llectal  examination  may  be  of  importance  here  also,  by  enabling  one 
to  locate  a  definite  mass  or  tumor  in  the  position  of  the  aj)pen<lix. 
Occasionally  rheumatic  children  will  show  rigidity  of  the  nmscular 
walls  of  the  abdomen.  Such  cases  are  without  temperature,  and  the 
symptoms  are  not  persistent. 

The  Blood  Count  In  Appendicitis. — In  a  broad  way  the  blood  count 
in  appendicitis  in  children  has  the  same  characters  and  the  same  value 
as  in  adult  life.  In  the  earliest  years  (under  five  years)  the  interpreta- 
tion of  the  blood  findings  may  be  rendered  less  certain  by  the  greater 
variability  of  the  blood  picture  and  the  greater  proportion  of  lymphocytes 
normally  found  in  the  blood  during  that  period;  but  appendicitis  is, 
happily,  rare  at  that  time,  and  the  reported  blood  counts  in  appendi- 
citis in  children  correspond  in  general  with  those  of  later  years.  The 
red  cells  are  asually  normal  in  number  and  appearance;  the  important 
changes  take  place  in  the  leukocytes.  There  is  regularly  a  leukocytosis, 
roughly  proportionate  to  the  severity  of  the  disease.  Thus  the  mild 
catarrhal  cases  may  show  no  increase  at  all  or  a  leukocytosis  of  12,000 
to  14,000.  A  count  of  lcS,000  or  more  will,  in  most  cases,  signify  an 
acute  suppurative  inflammation  with  or  without  spreading  peritonitis. 
Wliile  these  general  statements  may  be  made,  one  must  remember  that 
such  important  exceptions  occur  that  the  blood  count  alone  must  not 
be  relied  upon  to  determine  the  line  of  action  in  any  individual  case. 
The  blood  findings  must  always  be  taken  in  conjunction  with  the  other 
symptoms,  especially  the  temperature  and  local  signs.  As  Deaver  puts 
it,  the  changes  in  the  blood  should  be  regarded  as  simply  one  of  the 
symptoms  of  the  disease.  A  single  leukocyte  count  is  of  much  less 
value  than  a  series.  An  increasing  leukocytosis,  whatever  the  course  of 
the  temperature,  usually  means  an  advancing  process;  a  falling  leuko- 
cyte count,  on  the  other  hand,  regularly  indicates  a  retrogression  of  the 
inflammation.  It  is  to  be  remembered  that  in  some  of  the  worst  cases 
a  leukocytosis  may  not  be  found,  or  the  increase  in  number  of  white 
cells  is  slight.  The  absence  of  leukocytosis  may  then  be  regarded  as 
unfavorable,  as  it  is  in  pneumonia  or  diphtheria  (Cabot). 

The  differential  leukocyte  count  may  be  of  considerable  help  in  deter- 
mining the  presence  or  absence  of  pus.  A  percentage  of  polynuclear 
leukocytes  greater  than  SO  almost  surely  indicates  a  suppurative  or  gan- 
grenous process,  while  if  the  polynuclears  are  less  than  70  per  cent,  the 
process  is  quite  surely  catarrhal. 

Dowd  gives  the  following  observations  of  Sondem:  In  three  children 
who  had  gangrenous  appendices  the  polynuclear  percentage  was  86, 
85  8,  and  95.2,  while  the  number  of  leukocytes  was  7700,  14,000,  and 
29,800,  respectively.  In  three  other  patients  who  recovered  without 
operation  the  percentage  of  polynuclears  was  63.5,  62,  and  68,  while  the 


APPENDICITIS 


299 


corresponding  leukocyte  counts  were  25,000,  8800,  and  11,700.  It 
would  appear  from  these  counts  that  the  significance  of  the  differential 
count  remains  the  same,  whatever  the  total  number  of  leukocytes. 
The  caution  with  which  the  leukocyte  count  in  any  individ  iial  case  must 
be  interpreted  is  well  illustrated  by  these  counts,  since  in  a  gangrenous 
case  we  find  a  leukocytosis  of  only  7700,  while  a  count  of  25,000  is 
recorded  in  a  case  recovering  without  operation  and,  therefore,  presum- 
ably catarrhal.  The  accompanying  table  shows  the  results  of  the 
b'ood  examination  in  a  variety  of  cases: 


Sex. 

Age. 

Disease. 

White  cells. 

Remarks. 

Boy 

8  years 

Catarrhal  appendicitis. 

May    3, 

"      4, 

15,000 
14,0U0 

Recovered  without  operation. 

Boy 

11  years 

Suppurative  appendicitis. 

Sept.  22, 
"    23, 
"    24, 

20,500 
33,800 
32,000 

Differential  count,  Sept.  24— 
Polynuclears    .    .    .    82.3 
Lymphocytes  ...      5.3 
Large  mononuclears    11.0 
Eosinophlles    ...      1.3 

100.0 

Boy 

14  years 

Gangrenous  appendicitis. 

Nov.  11, 
"    12, 

16,000 
15,000 

Girl 

10  years 

Suppurative  appendicitis. 

Nov.  20, 

18,000 

Boy 

13  years 

Gangrenous  appendicitis, 
with  spreading  peritonitis. 

Nov.  27, 

"     28, 

17,000 
18,300 

Boy 

11  years 

Suppurative  appendicitis, 
with  abscess. 

Dec.    9, 
"    10, 

"     12, 

14.000 
13,900 
17,900 

Boy 

9  years 

Gangrenous  appendicitis. 

Dec.  18, 
"    19, 

18,100 
16,100 

Boy 

9  years 

Suppurative  appendicitis. 

Dec.  30, 

Jan.    2, 

"      4, 

"      5, 

24,000 
24,400 
23,300 
18,800 

Girl 

6  years 

Suppurative  appendicitis. 

Dec.  19, 
"    22, 

30,500 
27,000 

Operation  December  19. 

Girl 

12  years 

Suppurative  appendicitis. 

Dec.  30, 
Jan.    3, 

18,600 
12,000 

Operation  January  6. 
Appendicitis  with  abscess. 

Boy 

11  years 

Suppurative  appendicitis. 

Dec.  18, 
"    19, 

7,0n0 
15,600 

Differential  count,  Dec.  1 9— 
Polynuclears    .    .    .    82.4 
Large  mononuclears     7.6 
Lymphocytes  .    .    .    10  0 

lOU.O 
Operation  December  20. 
Appendicitis  with  large 
abscess. 

In  doubtful  cases  of  pus  formation  in  appendicitis  it  has  been  found 
that  the  determination  of  the  presence  of  iodophilic  granules  in  the 
leukocytes  is  of  some  value.  The  presence  of  numbers  of  such  granules 
within  the  leukocytes  is  regarded  as  evidence  of  pus  formation,  even  if 
temperature,  pulse,  and  leukocyte  count  be  indecisive;  and  the  absence 
of  the  iodine  reaction  is  good  evidence  that  no  suppuration  has  occurred. 
For  the  details  of  the  method  of  making  the  test  one  must  refer  to  books 
on  clinical  diagnosis. 


300  DISEASES  OF   THE   ALIMENTARY   TRACT 

Prognosis. — Appendicitis  is  always  a  grave  affection  in  a  child  and 
the  inorlality  in  series  of  ciises  ah'eady  reported  has  been  very  high. 
Earher  diagnosis  and  more  prompt  treatment  should  greatly  reduce 
this,  (ieneral  peritonitis  seems  to  he  more  frecjuent  among  children 
than  in  adults.  Of  57  causes  of  appendicitis  treated  in  two  years  in  the 
Presbyterian  Hospital  on  the  service  of  Dr.  McCosh,  7  were  under 
sixttH-n  years  of  age,  1  only  under  ten  years.  Of  these  7,  o  had  septic 
peritonitis.  Two  of  the  7  died  and  o  recovered.  Both  fatal  cases  had 
general  septic  jxM'itonitis. 

Treatment. — Every  case  of  appendicitis,  no  matter  how  mild,  should 
be  conlined  to  Ix'd.  If  vomiting  is  marked,  food  should  be  withheld, 
and  in  any  c;tse  only  fluids  should  be  allowed  during  the  acute  stage. 
The  l)owels  should  ix'  moved  once  daily  by  enema.  The  practice  of 
using  saline  purgatives  in  these  cases  has  been  abandoned. 

For  the  pain,  an  ice-bag  should  be  kept  over  the  appendix,  or  hot 
fomentations  emj)l()yed,  if  the  cold  is  objected  to.  ]\Ior})hine  or  opium 
should  Ix'  given  only  in  case  of  severe  pain.  There  is  no  doubt  that 
the  administration  of  these  drugs  by  numbing  the  sensibility  to  pain 
renders  judgment  of  the  condition  of  the  patient  more  difficult. 

For  the  rest  apjxMidicitis  is  almost  entirely  a  surgical  problem.  Radical 
surgeons  insist  upon  the  necessity  of  operating  upon  every  case  the 
moment  the  diagnosis  is  made.  ]\Iany  of  the  mild  cases  recover  within  a 
week  without  operation,  and  most  parents  as  well  as  patients  prefer  to 
avoid  operation,  if  it  is  possible.  Undoubtedly,  on  the  other  hand, 
immediate  ojxTation  lessens  the  risks  from  later  perforation,  and  under 
present  conditions  the  dangers  of  the  oj>erati()n  itself  are  slight.  In  the 
severe  cases  there  is  a  (juestion  Ix'tween  the  advisability  of  immediate 
operation  and  of  awaiting  the  formation  of  an  abscess.  The  tendency 
at  present  seems  to  be  to  operate  at  once  if  the  disease  has  not  existed 
more  than  forty-eight  hours.  After  that  time  it  is  advisable  to  delay 
operation  until  the  abscess  has  formed  and  become  easily  accessible. 

In  cases  of  recurrent  appendicitis,  operation  in  the  interval  has  come 
to  be  recognized  as  presenting  little  danger  and  the  best  prospect  of 
recovery. 

In  almost  every  case  of  appendicitis  there  are  surgical  problems 
which  re(juire  trained  judgment  and  skill,  and  therefore  surgical  advice 
should  be  regularly  sought  and  the  physician  should  welcome  the 
surgeon's  aid,  even  if  operation  is  not  imperative. 


ACUTE  PERITONITIS. 

Acute  inflammation  of  the  peritoneum  is  a  relatively  rare  occurrence 
in  childhood,  but  may  be  met  with  at  any  age.  It  is  seen  in  the  fetus 
and  is  much  more  common  in  the  newborn  than  in  the  later  periods. 

Etiology. — Acute  |)eritonitis  is  regularly  a  secondary  process,  although 
a  certain  number  of  cases  do  arise  in  which  it  is  difficult  or  impossible 
to  demonstrate  the  primary  factor.     In  the  newborn  acute  peritonitis 


ACUTE    PERITONITIS  301 

is  generally  secondary  to  some  infection  of  the  umbilicus,  suppuration  of 
the  umbilicus  or  in  its  vessels,  erysipelas  of  the  umbilicus,  etc.  In  rare 
instances  it  is  secondary  to  some  congenital  malformation,  such  as 
atresia  or  occlusion  of  the  rectum.  Syphilis  is  also  given  as  a  cause 
of  acute  peritonitis  in  the  newborn.  The  dangers  of  the  early  weeks 
passed,  infants  very  rarely  suffer  from  acute  peritonitis.  It  is  then  most 
often  secondary  to  inflammation  of  the  lung,  pleura  or  pericardium; 
it  is  not  uncommon  to  see  it  as  part  of  a  general  infection  of  the  serous 
membranes,  the  meninges,  pleurse,  and  pericardium.  It  may  be  sec- 
ondary to  the  acute  infectious  diseases:  typhoid,  dysentery,  erysipelas, 
scarlet  fever.  It  may  follow  severe  inflammation  of  the  intestine,  but  is 
surprisingly  rare  in  ileocolitis,  etc.  It  develops  in  the  course  of  intus- 
susception, strangulated  hernia,  or  ulcerative  processes  in  the  stomach 
or  intestine  with  perforation.  A  perforating  gastric  ulcer  in  childhood 
is  almost  unknown.  The  deep  ulcers  of  the  intestine,  typhoid,  tuber- 
culous, or  dysenteric,  very  rarely  perforate;  more  often  the  seat  of  the 
ulceration  is  shut  off  by  a  local  peritonitis.  Just  as  appendicitis  becomes 
more  frequent  with  each  year  in  childhood,  it  becomes  more  often  the 
cause  of  acute  peritonitis.  The  appendix  is  certainly  the  origin  of  most 
cases  arising  without  apparent  cause.  Acute  peritonitis  may  follow 
acute  inflammatory  or  suppurative  processes  in  any  of  the  viscera :  liver, 
spleen,  kidneys,  uterus,  and  tubes.  Abscesses  in  the  viscera  or  arising 
from  the  spinal  column  or  pelvic  bones  in  Pott's  disease,  etc.,  may 
rupture  into  the  peritoneum  and  set  up  acute  peritonitis. 

Gonorrheal  vulvovaginitis  may  lead  to  acute  peritonitis;  gonorrheal 
infection  in  boys  does  not  do  so. 

In  a  certain  number  of  cases  the  cause  of  the  peritonitis  not  being 
discoverable,  we  have  attempted  to  cover  our  ignorance  under  the 
designation  of  "rheumatic"  peritonitis. 

Pathology. — Bacteriologically,  we  find  the  staphylococcus,  strepto- 
coccus, pneumococcus,  or  the  colon  bacillus  in  most  of  these  cases.  The 
colon  bacillus  will,  of  course,  be  found  especially  with  perforation, 
appendicitis,  etc.  The  pneumococcus  is  frequently  found  in  cases 
secondary  to  pneumonia,  pleurisy,  or  pericarditis,  and  also  in  a  certain 
number  of  apparently  primary  or  "  rheumatic  "  cases.  The  gonococcus 
is  found  in  the  peritonitis  secondary  to  gonorrhea  in  the  female. 

Lesions. — In  the  earliest  stage  the  peritoneum  loses  its  clear,  shiny 
appearance  and  becomes  slightly  reddened  and  hazy.  If  the  process 
continues,  there  is  an  effusion  of  fibrin  alone,  or  fibrin  and  serum,  or 
pus.  In  the  fibrinous  cases  there  is  a  plastic  deposit  over  both  the 
parietal  and  visceral  peritoneum,  gluing  the  coils  of  intestine  and  all 
the  opposing  surfaces  together.  Usually  these  adhesions  are  very 
delicate  and  easily  separated,  but  in  old  cases  they  become  quite  firm. 
The  changes  of  acute  peritonitis  may  be  circumscribed,  but  in  children 
they  are  very  likely  to  be  general.  The  serous  effusion  is  rarely  large, 
the  serum  is  found  filling  the  pelvis  and  the  flanks.  It  may  be  clear,  but 
is  usually  cloudy  from  admixture  with  fibrin.  Pus  is  most  often  found 
in  cases  of  appendicitis  or  perforation.     In  these  cases  the  pus  has  a 


302  DISKASES  OF  THE  ALIMENTARY   TRACT 

very  characteristic,  foul,  fecal  odor.  The  amount  of  pus  may  be  small 
or  large.  It  collects  as  does  the  serum  especially  in  the  pelvis  and 
flanks.  The  collections  of  pus  may  be  encapsulated  in  any  part  of  the 
abdomen,  forming  localized  abscesses  which  may  perforate  through  the 
rectum,  bladder,  vagina,  or  even  the  abdominal  wall. 

Symptomatology.^! n  infants  the  symptoms  of  acute  general  peri- 
tonitis are  very  indefinite  and  uncertain.  Time  and  again  it  appears  at 
auto])sy,  when  it  has  not  been  suspected  during  life.  The  possibility  of 
the  onset  of  ])erit()nitis  must  be  borne  in  mind  in  every  case  of  infection 
al)()ut  the  navel,  likewise  the  frequency  with  which  peritonitis  follows 
pneumonia  or  pleurisy.  In  older  children  the  relationship  to  append- 
icitis should  be  remembered. 

The  onset  of  an  acute  peritonitis  in  a  child  is  frecjuently  obscured  by 
the  preceding  aflFection  such  as  pneumonia,  pleurisy,  or  appendicitis. 
If  there  has  been  no  fever  previously  observed,  it  now  appears,  or  if 
present  before,  it  is  increased.  The  temperature  is  usually  high,  103° 
to  104°  F.,  or  more,  but  a  lower  range  does  not  exclude  the  presence  of 
a  general  peritonitis.  Chills  may  occur  at  the  onset  or  at  any  time 
during  the  course.  The  patient  from  the  beginning  looks  and  acts  very 
sick,  the  eyes  appear  sunken,  and  symptoms  of  collapse — pallor,  small, 
feeble  pulse,  cold  extremities — appear  early.  The  respiration  is  rapid 
and  shallow,  and  almost  wholly  costal,  the  movements  of  the  diaphragm 
being  inhibited  on  account  of  pain.  The  pulse  is  rapid,  small,  and  hard. 
The  skin  of  the  body  is  hot  and  dry,  while  the  extremities  are  cold  and 
often  somewhat  cyanotic. 

There  is  nausea  from  the  beginning  and  vomiting  usually  follows 
and  continues  steadily  to  the  end.  Vomiting  may,  however,  be  almost 
absent  in  infants.  The  vomitus  after  the  evacuation  of  the  stomach 
contents  consists  of  mucus  and  watery,  bile-tinged  fluid.  The  urine  is 
diminished  in  amount,  dark  in  color,  and  contains  indican  in  abundance. 
There  may  be  difficulty  in  urination  on  account  of  pain  excited  by  the 
movement  of  the  abdominal  muscles;  there  may  be  retention,  or  the 
urine  may  be  passed  frecpiently  in  small  quantities.  The  condition  of 
the  bowels  varies.  The  obstinate  constipation  of  adults  is  not  so  frequent 
in  children,  the  bowels  may  move  normally  or  there  may  even  be  a 
diarrhea.  The  local  signs  are  of  quite  as  much  importance  as  the 
constitutional  symptoms.  Infants  usually  lie  flat  on  the  back  with  the 
limbs  straight.  In  children  we  may  see  the  characteristic  attitude  with 
the  knees  drawn  up.  The  abdomen  is  usually  full,  tense,  tympanitic, 
and  very  tender  to  touch.  There  is  a  marked  rigidity  of  all  the  abdom- 
inal muscles.  The  pain  and  tenderness  may  be  so  great  that  even  the 
slightest  motion,  or  touch,  or  the  weight  of  the  bed-clothes  excites  pain 
and  causes  the  child  to  cry  out.  The  tension  of  the  abdomen  may  be 
visible;  it  is  usually  l)etter  appreciated  by  touch.  The  muscular  rigidity 
is  a  sign  of  considerable  importance.  It  is  very  rare  that  the  effusion  of 
serum  or  pus  reaches  a  sufficient  amount  to  give  dulness  in  the  flanks. 
If  the  exudate  is  encapsulated,  it  gives  rise  to  a  localized  dulness  which 
should  be  sought  for  by  light  percussion, 


ACUTE  PERITONITIS  303 

The  course  of  an  acute  peritonitis  varies  greatly  with  the  age  of  the 
patient  and  the  condition  underlying  it.  The  onset  is  often  violent,  the 
fever  high,  vomiting  or  hiccough  persistent,  the  collapse  marked  from 
the  beginning,  and  death  ensues  in  from  twelve  to  forty-eight  hours. 
Especially  in  the  newborn  is  the  rapid  course  seen,  and  all  the  char- 
acteristic symptoms  may  be  wanting.  The  cases  of  perforative  peri- 
tonitis are  also  very  swiftly  fatal,  as  a  rule.  Acute  peritonitis,  non- 
suppurative in  older  children,  runs  a  more  favorable  course,  many  of  the 
children  recovering  after  one  or  two  weeks,  with  a  gradual  subsidence 
of  the  symptoms.  The  gonococcal  peritonitis  usually  runs  a  favorable 
course. 

In  cases  in  which  the  process  becomes  localized,  the  temperature  may 
assume  a  hectic  type,  an  abscess  may  form,  and  the  process  continue  for 
weeks,  until  the  abscess  ruptures  or  is  opened. 

Diagnosis. — The  diagnosis  of  acute  general  peritonitis  must  rest  in 
most  cases  upon  the  combination  of  the  constitutional  and  local  symp- 
toms, aided  in  many  cases  by  the  previous  existence  of  some  source  of 
infection,  such  as  an  inflamed  navel  or  an  appendicitis.  With  a  typical 
case  the  diagnosis  is  easily  made,  but  as  already  noted  the  characteristic 
symptoms  are  often  wanting,  especially  in  infants,  and  the  disease  is 
overlooked.  The  presence  of  abdominal  distention  with  tympany, 
acute  pain  on  the  slightest  touch,  rigidity  of  the  abdominal  muscles, 
absence  of  respiratory  movement,  and  the  constitutional  evidences  of 
severe  illness  should  enable  one  to  make  a  diagnosis,  but  oftentimes  the 
abdominal  examination  elicits  only  doubtful  or  uncertain  signs,  and  it 
is  difficult  or  impossible  to  reach  a  conclusion. 

Prognosis. — Acute  peritonitis  is  always  a  grave  and  generally  a  fatal 
affection  in  childhood.  All  cases  in  infancy  are  fatal.  All  the  cases 
depending  upon  perforation  in  older  children  are  fatal.  Acute  general 
peritonitis  following  appendicitis  is  regularly  fatal.  Of  recent  years 
prompt  operation  has  saved  a  number  of  such  cases.  The  so-called 
primary  cases  usually  run  a  more  favorable  course,  as  does  also  the 
gonococcal  peritonitis. 

Treatment.— While  the  treatment  of  these  cases  is  essentially  surgical, 
some  suggestions  as  to  medical  care  are  necessary  when  surgical  inter- 
vention is  not  possible.  The  patient  is  to  be  kept  as  nearly  as  possible 
absolutely  quiet  in  bed.  At  the  onset  the  bowels  may  be  freely  moved 
by  salines,  later  no  purgative  should  be  given  by  mouth.  Cold  should 
be  applied  to  the  abdomen  by  the  Leiter  coil,  and  care  taken  to  keep 
the  flow  constant.  Many  children  will  not,  however,  endure  the  appli- 
cation of  cold,  and  heat  must  be  employed  to  relieve  pain.  This  can 
best  be  done  by  spongiopiline  or  flannel  wrung  out  of  hot  water,  the 
application  to  be  frequently  renewed  to  get  the  best  effect  of  the  heat. 
A  few  drops  of  turpentine  may  be  sprinkled  on  the  cloth,  to  increase 
the  counterirritation.  It  is  very  doubtful  whether  these  measures  do 
more  than  relieve  pain,  but  they  are  useful  for  that  purpose.  Morphine 
is  to  be  used  hypodermically  for  the  same  purpose  and  to  quiet  peris- 
talsis.     For  a  child  of  five  years  0.003  gm.  (a  twentieth  of  a  grain)  may 


304  DISEASES  OF   THE  ALIMENTARY   TRACT 

he  given  as  the  initial  doso,  and  this  amount  repeated  every  two  or  three 
hoin-s.  Thv  dose  must,  of  course,  be  regulated  by  its  effect  upon  the 
patient.  The  hypodermic  use  of  morphine  is  certainly  preferable  to 
the  administration  of  opium  by  the  mouth  or  rectum,  but  in  some  cases 
the  latter  method  may  be  necessary.  For  a  child  of  five  years  we  may 
then  begin  with  three  drops  of  huulanum,  and  repeat  it  as  iiecessary. 
The  constipation  produced  by  the  use  of  the  opium  or  morphine  is  not 
unfavorable  and  no  effort  need  be  made  to  move  the  l:)owels  for  as  much 
as  a  week.  Then  enenuita  should  be  employed.  Schreiber  records  a 
case  in  which  a  child  suffering  from  peritonitis  and  under  the  opium 
treatment  went  twenty-two  days  without  a  movement  of  the  bowels 
without  harm. 

The  feeding  of  th(>  patients  is  important.  In  the  early  stages  with 
much  vomiting  nothing  should  be  given  by  mouth.  Any  medication 
necessary  should  be  given  hypodermically  or  by  the  rectum.  The 
stomach  m:iy  be  washed  out  with  advantage,  if  the  vomiting  is  severe. 
After  forty-eight  hours,  feeding  may  be  tried.  Peptonized  milk,  matzoon, 
kumvss,  and  beef-juice  or  other  concentrated  and  easily  digested  foods 
mav  be  employed.  The  food  nuist  be  given  in  small  quantities  and  not 
oftener  than  once  in  two  hours.  Attempts  to  press  feeding  will  only 
result  in  increased  vomiting. 

For  the  relief  of  the  distressing  thirst  small  bits  of  ice  may  be  given, 
to  Ik^  held  in  the  mouth;  the  ice  also  serves  to  allay  the  irritability  of  the 
stomach  and  relieve  either  vomiting  or  hiccough.  If  the  temperature 
is  very  high,  cool  sponging  may  be  employed  to  the  chest  and  hmbs. 

Stimulants  are  refpiired  for  the  failing  pulse.  Champagne  is  usually 
better  l)orne  than  any  other  form  of  alcohol.  A  good  whiskey  is  better 
than  a  poor  brandy.  Strychnine,  camphor,  or  whiskey  may  be  used 
hypodermically. 

As  the  patient  shows  improvement  the  opium  is  to  be  gradually 
withdrawn. 

In  cases  of  perforative  peritonitis  the  only  hope  of  the  patient  lies  in 
earlv  surgical  interference. 

With  improvement  of  technique  in  recent  years  much  better  results 
than  were  formerly  known  have  been  obtained  by  laparotomy  in  these 
cases.    Whenever  pus  has  formed,  operative  treatment  is  imperative. 


CHRONIC  PERITONITIS. 

Etiology. — The  occurrence  of  a  primary  chronic  peritonitis  not 
tul)cr(ul()us  was  imtil  recently  doubted,  and  even  now  some  maintain 
that  this  [)rocess  is  always  tuberculous. 

The  work  of  Clalvagni,  ^'ierordt,  Henoch  and  others  has,  however, 
established  the  existence  of  an  independent  chronic  peritonitis.  It  is 
v<>ry  rare.  It  occurs  mostly  in  children  from  six  to  twelve  years  of  age. 
The  causation  is  very  obscure.  Pvxposure  to  cold  and  wet,  injury, 
rheumatism,  or  measles  has  preceded  the  onset, 


ASCITES  305 

Pathology. — Very  few  autopsies  have  been  recorded.  In  a  case  of 
Henoch  about  500  c.c.  of  turbid  fluid  were  found  in  the  abdomen, 
with  many  adhesions  between  the  loops  of  small  intestine  and  an  enor- 
mous, fibrous  thickening  of  the  peritoneum  in  general.  There  were  no 
traces  of  tuberculosis. 

Symptomatology. — The  aifection  develops  very  insidiously.  There 
may  be  slight  digestive  disturbances.  The  chief  and  frequently  the 
only  sign  of  the  disease  is  a  gradually  increasing  ascites,  which  gives 
the  usual  physical  signs.  Usually  the  effusion  is  serous,  sometimes  sero- 
fibrinous; the  fluid  may  have  a  greenish  color.  In  the  serofibrinous 
cases  there  may  be  a  little  evening  temperature  and  nodular  masses  may 
be  felt  in  the  abdomen.  There  may  be  anemia  and  some  loss  of  weight, 
but,  as  a  rule,  the  general  health  is  not  markedly  affected.  After  weeks 
or  months  the  fluid  is  gradually  absorbed  and  there  is  a  complete  return 
to  health. 

Diagnosis. — The  important  point  is  to  distinguish  this  affection  from 
tuberculous  peritonitis.  The  points  in  differential  diagnosis  are  given 
under  the  latter  subject.     (See  page  373.) 

Treatment. — This  must  be  conducted  on  the  lines  of  the  medicinal 
treatment  of  tuberculous  peritonitis. 

ASCITES. 

By  ascites  we  understand  a  collection  of  serum  in  the  peritoneal 
cavity.  It  is  a  symptom  and  not  a  disease.  Ascites  may  arise  in  any 
form  of  chronic  peritonitis,  simple  or  tuberculous.  It  may  be  produced 
by  obstruction  to  the  portal  circulation,  by  cirrhosis  of  the  liver,  by 
tumors,  such  as  masses  of  enlarged  lymph  nodes,  pressing  upon  the 
portal  vein;  by  obstruction  to  the  circulation  in  the  lungs  from  chronic 
pneumonia;  by  cardiac  failure  of  any  kind.  It  may  be  part  of  a  general 
anasarca,  such  as  occurs  in  chronic  nephritis,  severe  anemia,  or  cachexia. 

Symptomatology. — The  physical  signs  of  ascites  are  distinctive.  The 
abdomen  is  distended,  tense,  and  symmetrical.  If  the  patient  lies  upon 
the  back,  there  is  resonance  over  the  central  parts  of  the  abdomen  with 
dulness  in  the  flanks.  If  the  patient  turns  on  one  side,  the  fluid  sinks 
to  the  other  side,  with  the  line  dulness  rising  higher  on  that  side  and 
resonance  in  the  uppermost  side.  If  the  patient  sits  the  dulness  is 
in  the  lower  parts  of  the  abdomen  and  the  upper  parts  are  resonant. 
With  the  patient  lying  upon  the  back  tapping  one  side  of  the  abdomen 
with  the  fingers  gives  rise  to  a  fluid  wave  which  can  be  felt  by  the  fingers 
of  the  other  hand  placed  on  the  other  side  of  the  abdomen.  A  similar  wave 
may  be  obtained  in  a  tympanitic  abdomen,  but  if  an  assistant  places 
the  ulnar  border  of  one  hand  on  the  linea  alba  and  presses  firmly  down- 
ward the  wave  in  a  tympanitic  abdomen  is  cut  off,  while  that  trans- 
mitted through  fluid  is  not  interrupted. 

A  considerable  collection  of  fluid  in  the  abdomen  displaces  both  liver 
and    heart  upward  and    may  give    rise  to  dyspnea    or  considerably 
embarrass  the  heart  action. 
20 


306  DISEASES  OF   THE  ALIMEXTARY   TRACT 

Tlir  fluid  in  a.scites  is  alkaline  in  reaction,  usually  clear,  and  of  a 
liglit-yellow  color.  The  specific  <T;ravity  varies  from  1005  to  1020, 
averaging  1010.  The  albumin  content  is  generally  not  over  1  to  2  per 
cent.  In  children  a  very  few  cases  of  chylous  ascites  have  been  reported, 
the  fluid  having  a  milky-white  color  from  admixture  with  fat.  Fat  is 
supposed  to  occur  in  the  ascitic  fluid  by  reason  of  some  pressure  upon 
the  lacteal  system,  but  this  has  not  been  satisfactorilv  demonstrated  in 
cases  in  which  examination  has  been  possible.  Fatty  degeneration  of 
the  cellular  elements  of  the  fluid  has  also  been  suggested  as  an  expla- 
nation, but  this  does  not  seem  sufficient  to  account  for  the  quantity  of 
fat  jiresent  in  these  conditions.  The  j)rcssure  of  a  chylous  ascites  adds 
to  tile  gra^■ity  of  the  condition;  one  case  of  recovery  has,  however,  been 
reported. 

Treatment. — The  treatment  of  ascites  is  that  of  the  underlvins:  con- 
dition.  Whenever  the  quantity  of  fluid  is  sufficient  to  give  rise  to  much 
pressure  or  interfere  with  the  action  of  the  heart  or  lungs  it  should 
be  removed  by  paracentesis. 


PROCTITIS. 

Inflammation  of  the  rectum  occurs  to  some  extent  in  nearly  all  cases 
of  marked  inflammatory  processes  in  the  colon  or  sigmoid  flexure.  It 
may,  however,  occur  independently,  and  in  this  form  merits  separate 
consideration. 

Etiology. — Proctitis  may  be  produced  either  by  a  local  irritation  or 
infection  or  a  combination  of  these  two  factors.  The  presence  of  thread- 
worms, traumatism  in  the  use  of  suppositories  or  injections,  or  the  use 
of  irritating  materials  in  either  of  these  forms  may  excite  a  proctitis. 
Infection  may  be  conveyed  in  cases  of  gonorrhea  or  syphilis,  or  from 
the  use  of  infected  instruments,  such  as  rectal  tubes  or  douche  nozzles. 

Pathology. — There  may  be  a  simple  catarrhal  inflammation,  with 
redness,  swelling,  and  increased  secretion  of  mucus;  pseudomembranous 
inflammation  with  conditions  similar  to  those  seen  in  pseudomem- 
l)ranous  ileocolitis;  or  ulceration,  which  may  be  the  multiple  follicular 
type  seen  in  the  colon,  or  single,  larger  ulcers.  The  large  ulcers  may  be 
produced  by  the  fusion  of  a  number  of  small  follicular  ulcers,  or  may 
be  simply  catarrhal,  or  in  rare  cases  tuberculous. 

Symptomatology. — Inflammation  of  the  rectum  alone  produces  a  fairly 
characteristic  picture.  There  are  frequent  movements  of  the  bowels, 
perhaps  as  many  as  fifteen  or  twenty  a  day,  each  movement  being  accom- 
panied with  straining  and  fretfulness  or  crying,  indicating  pain.  The 
reflex  action  of  the  rectum  may  be  so  increased  that  the  movements  are 
proje  tile  and  expellerl  suddenly.  The  movements  for  the  most  part 
con.sist  of  mucus  alone,  or,  if  ulcers  be  present,  mingled  with  blood. 
They  are  followed  by  tenesmus.  In  the  pseudomembranous  cases  bits 
of  the  pseudomembrane  may  be  found  in  the  .stools  by  washing  them, 
as  in  pseudomembranous  ileocolitis.    Three  or  four  times  daily  there  will 


PROLAPSE  OF   THE  ANUS  AND  RECTUM  307 

occur  free  movements  of  the  bowels,  which  are  yellow  and  almost  normal. 
The  annoyance  of  the  frequent  movements,  together  with  the  straining 
and  pain,  may  produce  wasting,  pallor,  and  prostration.  In  some  cases 
prolapse  of  the  rectum  may  be  caused,  and  in  these  cases  the  character 
of  the  inflammatory  process  may  be  observed  in  the  prolapsed  portion 
of  the  bowel.  In  other  cases  inspection  through  a  speculum  dis- 
closes catarrhal  or  pseudomembranous  inflammation,  with  or  without 
ulceration.  There  is  regularly  more  or  less  excoriation  about  the  anus 
from  the  irritation  of  the  frequent  passages. 

Diagnosis. — The  condition  is  most  often  confused  with  ileocolitis. 
The  diagnosis  should  be  made  on  the  observation  of  the  occurrence  of 
some  fairly  normal  movements,  while  the  other  passages  consist  almost 
wholly  of  mucus  or  mucus  and  blood,  which  are  evacuated  suddenly 
with  straining  and  pain.  Inspection  of  the  rectum  shows  the  local 
inflammation. 

Treatment. — If  a  direct  cause  of  the  inflammation  can  be  found,  such 
as  the  presence  of  thread-worms  or  the  use  of  irritating  suppositories, 
the  removal  of  the  cause  may  be  all  that  is  required.  Ulcers  will  require 
touching  with  carbolic  acid  or  a  silver-nitrate  point. 

Most  cases  require  the  use  of  cleansing  injections  and  salt  solution, 
4  gm.  to  500  c.c.  (1  drachm  to  1  pint),  or  a  saturated  solution  of  boric 
acid.  These  injections  should  be  given  warm  and  a  sufficient  quantity, 
500  c.c.  (1  pint),  employed  to  thoroughly  cleanse  the  rectum.  After 
these  cleansing  injections  Starr  recommends  the  introduction  of  8  gm. 
(2  drachms)  of  olive  oil  or  equal  parts  of  olive  oil  and  lime-water.  Such 
injections  should  be  employed  twice  daily  at  first,  later  once  a  day. 

In  more  obstinate  cases  after  cleansing  the  rectum  with  plain  water 
an  astringent  injection  of  tannin,  1  gm.  to  50  c.c.  (10  grains  to  the  ounce), 
or  nitrate  of  silver,  0.1  gm.  to  50  c.c.  (1  grain  to  the  ounce),  should  be 
introduced,  and  after  five  or  ten  minutes  the  excess  washed  out  either 
with  plain  water  or  the  salt  solution. 

Such  astringent  injections  are  to  be  repeated  at  intervals  of  two  or 
three  days,  until  improvement  is  noted;  then  the  simple  injections  of 
salt  solution  or  boric  acid  may  be  relied  upon  to  complete  the  cure. 

In  the  severer  cases  rest  in  bed  must  be  required  and  any  digestive 
disturbance  treated  by  proper  dietetic  measures.  Where  there  is  much 
tenesmus  after  the  movements  suppositories  of  cocaine,  0.015  to  0.06  gm. 
(I  to  1  grain),  may  be  employed  for  relief.  For  the  excoriation  about 
the  anus  the  oxide  of  zinc  ointment  is  the  best  application. 

PROLAPSE  OF  THE  ANUS  AND  RECTUM. 

There  are  three  degrees  of  prolapse  of  the  rectum:  1.  A  protrusion 
of  the  mucous  mem.brane  of  the  rectum  through  the  anus,  which  is 
usually  a  prolapse  of  the  anus.  2.  A  protrusion  of  the  whole  rectal  wall 
through  the  anus.  3.  An  invagination  of  the  upper  part  of  the  rectum 
into  the  lower,  with  protrusion  of  the  invaginated  part.  This  should  be 
considered  as  an  intussusception. 


308  DISEASES  OF   THE  ALIMENTARY    TRACT 

Etiology. — Prolapse  of  the  rectum  is  seen  most  often  in  children  two 
or  three  years  of  age.  Any  condition  that  produces  frequent  violent 
straining  may  cause  prolapse,  especially  phimosis,  contracted  meatus 
urinarius,  stone  in  the  bladder,  cystitis,  chronic  constipation,  diarrhea, 
polyp  of  the  rectum,  violent  coughing,  as  pertussis,  etc. 

It  appears  that  there  must  also  be  some  weakness  of  the  levator  ani  and 
the  anal  sphincter  in  these  cases.  It  is  frequently  found  in  children  whose 
nutrition  is  \Mtov  and  whose  muscles  are  weak,  especially  in  the  marantic. 

Symptomatology. — -With  prolapse  of  the  rectum  a  tumor  appears  at 
the  anal  orifice.  In  the  simpler  form  this  is  nothing  more  than  a  fold 
of  mucous  membrane  surrounding  the  anal  orifice.  When  the  whole 
wall  of  the  rectum  protrudes  a  flattened,  conical  tumor  is  formed,  the 
base  being  at  the  anal  margin,  the  flattened  top  surrounding  the  central 
orifice.  The  mucous  membrane  covering  the  tumor  appears  dark  red 
or  purple,  covered  with  mucus,  and  not  infrequently  showing  more  or 
less  ulceration  or  fissures.  There  is  regularly  some  bleeding  from  the 
exposed  surface  and  a  free  discharge  of  mucus.  At  first  the  tumor 
appears  only  with  defecation  and  is  easily  reduced.  I^ater,  the  prolapse 
occurs  at  other  times,  the  tumor  is  reduced  with  more  difficulty,  and 
may  remain  down  constantly.  There  is  little  or  no  obstruction  to 
defecation,  but  the  irritation,  pain,  and  discharge  of  mucus  and  blood 
weaken  the  patient  and  he  becomes  pale  and  loses  flesh  and  strength. 
The  sphincter  ani  is  regularly  greatly  relaxed  and  patulous;  but  in  some 
cases  the  prolapsed  portion  of  the  rectum  may  be  constricted  by  the 
sphincter  and  sloughing  ensue. 

Diagnosis. — The  diagnosis  of  the  condition  is  made  on  examination. 
Polvji  of  the  rectum  and  hemorrhoids  have  l)een  confused  with  prolapse. 
A  polyp  is  a  single,  isolated,  and  pedunculated  mass.  Hemorrhoids  are 
not  common  in  children  and  never  form  a  complete  ring.  They  have 
the  characteristic  appearance  of  dilated  veins.  The  intussusceptum  in 
an  intussusception  may  appear  at  the  anus,  but  the  constitutional  symp- 
toms of  this  condition  and  the  presence  not  onlv  of  a  central  opening, 
but  of  a  space  between  the  intussusceptum  and  the  rectal  wall,  render 
diff<'rcntiation  easy. 

Treatment. — In  the  milder  cases  relief  of  the  cause  of  straining  may 
be  sufficient  to  cure  the  prolapse.  If  the  prola])se  occurs  only  at  the 
time  of  defecation,  the  bowels  should  be  kept  moving  easily  and  the 
child  should  be  made  to  have  all  its  movements  lying  on  one  side,  the 
erect  and  sitting  position  always  favoring  the  prolapse.  It  is  sometimes 
useful  to  support  the  anus  during  defecation  by  pressure  at  the  sides 
or  by  drawing  the  skin  tightly  to  one  side. 

When  the  prolapse  occurs  constantly,  it  may  be  prevented  by  keeping 
the  child  in  bed  and  strapping  the  buttocks  tightly  together  or  putting 
on  a  firm  T-bandage. 

The  prolapse  must  be  reduced  whenever  it  occurs.  Usually  this  is 
easily  accomplished,  but  if  the  tumor  is  large  it  may  be  necessary  to 
apply  fomentations  or  ice  for  a  time  to  reduce  the  swelling,  or  an  anes- 
thetic may  be  required. 


POLYPUS  OF  THE  RECTUM  309 

If  the  prolapse  is  due  to  diarrhea  and  tenesmus,  the  straining  may  be 
reheved  by  sponging  the  anus  with  cold  water  or  inserting  suppositories 
of  cocaine  0.015  to  0.06  gm.  {\  to  1  grain). 

Astringent  injections  of  tannin,  2  to  4  gm.  to  30  c.c.  {\  to  1  drachm 
to  the  ounce),  or  the  infusion  of  quassia,  60  to  120  c.c.  (2  to  4  ounces), 
may  be  employed  once  or  twice  daily  in  the  severer  cases. 

Holt  recommends  local  injections  of  strychnine  sulphate,  0.0006  gm. 
(tw  grain),  twice  daily,  for  a  child  of  two  years,  to  improve  the  tone  of 
the  sphincter  and  levator  ani. 

Where  other  measures  fail  cauterization  may  be  employed.  With 
the  actual  cautery  four  or  five  narrow  lines  are  drawn  from  the  centre  of 
the  prolapsed  portion  to  the  margin,  only  the  mucous  membrane  being 
burnt  through. 

The  tumor  is  then  reduced  and  a  pad  applied  to  prevent  recurrence. 
The  resulting  cicatrization  usually  cures.  As  a  substitute  for  this 
procedure,  wedge-shaped  areas  of  the  mucous  membrane  may  be 
excised  and  the  edges  brought  together  (Ashby  and  Wright). 

In  nearly  all  cases  success  can  be  had  by  the  patient  application  of 
the  milder  measures,  most  of  the  cases  being  cured  in  a  few  weeks,  but 
from  time  to  time  obstinate  cases  are  seen  which  will  yield  only  to  the 
operative  procedures. 


POLYPUS  OF  THE  RECTUM. 

Polypi  of  the  rectum  are  more  common  in  childhood  than  at  any 
other  time  of  life.  The  cause  of  the  growths  is  unknown.  Huber  has 
observed  their  association  with  adenoids.  They  are  a  fairly  frequent 
cause  of  bleeding  from  the  rectum  in  children. 

Pathology. — Pathologically  the  tumors  are  classed  as  fibromata,  or 
myxofibromata,  or  adenomata.  The  fibrous  tumors  are  usually  smooth 
on  the  surface,  sometimes  excoriated,  and  may  be  sessile,  but  are  often 
attached  by  a  long,  thin  pedicle.  The  adenomata  are  granular  or 
warty  in  appearance. 

The  tumors  vary  in  size  from  that  of  a  pea  up  to  that  of  a  cherry  or 
hazel-nut.  They  may  be  either  single  or  multiple.  The  anterior  wall 
of  the  rectum  about  an  inch  from  the  anus  is  the  common  seat  of  these 
growths,  but  they  may  occur  at  any  part. 

Symptomatology.— Polypi  of  the  rectum  produce  irritation,  with 
tenesmus  and  discharge  of  mucus  or  blood.  Blood,  when  passed,  is 
rarely  mixed  with  mucus,  is  usually  quite  clear,  and  may  amount  to  a 
drachm  or  more.  The  repeated  bleeding  may  produce  anemia.  At  times 
the  polyp  may  be  protruded  through  the  anus  and  its  pedicle  constricted, 
so  that  the  tumor  sloughs  off  and  is  passed  in  a  stool.  In  other 
instances  the  dragging  of  the  tumor  produces  a  prolapse  of  the  rectum. 

Treatment. — The  pedunculated  tumors  may  be  simply  twisted  off 
or  may  be  ligatured  and  snipped  off  with  the  scissors.  The  operation 
may  require  anesthetization  and  the  use  of  a  speculum. 


310  DISEASES  OF    THE   ALIMEXTARY   TRACT 

Sessile  polyj)!  may  give  rise  to  no  symptoms.  In  mild  cases  they  may 
be  treated  by  astringent  injections  of  alum,  a  1  per  cent,  solution, 
injected  once  or  twice  daily.  In  severe  cases  the  base  of  the  growth  may 
be  ligatured,  and,  after  removal  of  the  mass  by  the  scissors,  cauterized. 


HEMORRHOIDS. 

Hemorrhoids  are  decidedly  uncommon  in  children,  but  both  the 
internal  and  external  varieties  have  been  observed.  They  are  nearly 
alwavs  dependent  upon  chronic  constipation,  and  in  that  case  are  most 
likely  to  be  external.  The  symptoms  produced  by  piles  in  children  are 
practically  limited  to  slight  hemorrhage  accompanying  movements  of 
the  bowels,  particularly  if  the  stools  are  hard  and  passed  by  straining. 
Ill  rare  instances  the  tumors  are  protruded. 

Treatment. — 'i'he  relief  of  the  constipation  is  usually  all  that  is  required. 
Ilolt  has  never  seen  hemorrhoids  in  a  child  necessitating  operative 
treatment. 

ISCHIORECTAL  ABSCESS. 

Iscliiorectal  abscess  is  not  uncommon  in  children.  The  abscess 
results  from  infection  of  the  lymph  nodes  or  the  cellular  tissue  of 
the  ischiorectal  region.  The  source  of  infection  is  the  rectum,  in  which 
there  may  be  active  inflammation  or  ulceration.  Not  infrequently 
ischiorectal  abscess  arises  without  its  being  possible  to  demonstrate  the 
source  of  the  infection.  The  symptoms  are  those  of  abscess  anywhere, 
fever,  local  redness,  swelling,  pain,  and  tenderness.  The  abscess  may 
present  externally  or  be  felt  bulging  into  the  rectum  on  examination  w  ith 
the  finger. 

Treatment.— The  treatment  consists  in  laying  open  the  abscess, 
cleansing  it  with  hydrogen  peroxide,  and  packing  it.  The  abscesses 
regularly  heal  promptly.     Fistula  in  ano  Ls  rarely  produced  in  children. 


INTESTINAL  WORMS. 

These  intestinal  worms  or  parasites  comprise  quite  a  number  of 
animals  of  the  lower  orders  which  exist  in  the  mature  condition  in  the 
intestine  of  man,  drawing  their  nourishment  either  from  the  ho^^t's  blood 
or  from  the  contents  of  the  parts  in  which  they  live.  Infection  is  said  to 
be  more  frequent  among  children  than  among  adults,  but  except  among 
recent  immigrants  intestinal  parasites  are  uncommon  in  either  class 
in  this  country.     The  parasites  most  frequentlv  found  in  children  are: 

1.  Cestodes,  including  tjenia  solium  (Fig.  56);  taenia  saginata,  or 
mediocanellata   (Fig.   57);    bothriocephalus  latus   (Figs.   58  and   59). 

2.  Nematodes:  ascarides,  ascaris  lumbricoides,  oxyuris  vermicularis 
(Figs.  60,  61  and  62).  3.  Strongyloides,  ankylostomum  duodenale 
(Figs.  63,  64,  65  and  66). 


INTESTINAL  PARASITES 


311 


Tsenise  or  Tape-worm.  Modes  of  Infection.— Each  of  these  tsenise 
passes  through  a  hfe  cycle  of  three  stages:  1.  The  egg.  2.  The  embryo 
or  larva.  3.  The  mature  worm.  The  full-grown  parasites  are  found 
only  in  the  intestinal  canal  of  man.  Eggs  are  passed  from  any  of  the 
segments  of  the  worm,  mingle  with  the  feces,  and  are  passed  from  the 
host.  For  its  further  development  the  egg  must  be  taken  into  the 
alimentary  tract  of  another  animal.  Thus  the  egg  of  the  teenia  solium 
finds  its  refuge  in  the  intestine  of  the  hog.  There  the  capsule  of  the 
egg  is  dissolved,  the  egg  develops  into  an  embryo  wliich  passes  through 
the  intestinal  wall  into  the  muscles  of  the  host,  by  virtue  of  certain 
small,  hook-like  processes  on  the  head,  and  then  becomes  encysted.  An 
animal  whose  muscles  are  full  of  these  encysted  larvae  is  spoken  of  as 
"measly"  or  "measled."     The  larvae  remain    in    this  state  until  the 


Fig.  56 


Ys 


1.  Head  of  taenia  solium;  magnification,  50;  2,  3,  mature  and  semimature  segments,  natural  size ; 
4,  two  proglottides  with,  uterus,  twice  magnified.    (From  Ziegler,  after  Leuckart.) 


flesh  of  the  host  is  consumed  as  meat  by  man,  when  they  are  set  free 
in  the  intestine,  where  they  develop  into  mature  worms  and  their  life 
cycle  is  complete.  For  the  taenia  saginata  cattle  are  the  intermediate 
hosts;  for  the  bothrioceplialus  latus  fish. 

It  is  possible  that  man  himself,  taking  the  ova  of  any  of  these  worms 
into  the  stomach,  may  become  the  intermediary  host — i.  e.,  lodge  the 
larval  form.  This  is  known  to  happen  in  the  case  of  taenia  solium,  the 
encysted  larvae  of  which,  the  cysticercus  cellulosae,  are  sometimes  found 
in  human  muscle,  the  brain,  etc. 

Toenia  Saginata  or  Mediocanellata. — This  is  the  most  common  tape- 
worm in  Europe  and  this  country.  Infection  occurs  through  eating 
"measly"  beef.     The  length  of  the  parasite  varies  from  4  to  8  metres 


312 


DISEASES  OF  THE  ALIMENTARY  TRACT 


(15  to  30  feet).  The  head  is  surrounded  by  four  pigmented  suckers. 
The  indivi<hiul  segments  are  (juite  thick  and  opa(jue,  and  (Hniimsh 
in  size  toward  the  liead,  the  largest  measuring  2  to  3  cm.  Kacli 
segment  contains  a  many  l)ranchcd  (20)  uterus.  The  ova  arc  shghtly 
oval,  or  round,  are  yellowish  brown  in  color,  have  a  thick  caj)sulc,  antl 
measure  30  to  40  x  25  to  35  microns. 

Fig.  57 


Tsenia  sagiinua  :    a,  naiiiiiil  size;  b,  much  enlarged;  e,  ova  much  enlarged.    (Simon.) 


Tcpnia  solium  is  shorter  than  tlie  tji^nia  saginata,  measuring  from 
2  to  3  metres,  as  a  rule,  rarely  reaching  a  length  of  G  to  8  metres.  The 
head  is  very  small,  is  provided  with  four  suckers,  and  with  a  rostellum 
armed  withadouble  row  of  booklets, twenty-four  to  twenty-six  in  number, 
"^riie  mature  .segments  measure  from  1  to  1.5  cm.  in  length,  C)  to  7  mm. 
in  breadth,  and  contain  a  uterus  with  only  five  to  .seven  branches.  The 
ova  are  round,  of  a  brownish  color,  are  surrounded  wnth  a  thick,  radially 


INTESTINAL  PARASITES 


313 


streaked  membrane,  and  in  their  interior  the  hooklets  of  the  embryo 
can  usually  be  made  out.  Their  diameter  is  30  to  35  microns.  They 
can  hardly  be  distinguished  from  the  ova  of  the  saginata.  The  life 
cycle  of  the  taenia  solium  is  the  same  as  that  of  taenia  saginata  except 
that  the  hog  is  the  intermediary  host. 


Fig.  58 


jMiddle  pieceof  a  proglottis  of  bothriocephalus  latus,  seen  from  the  dorsal  surface,  the  externHl 
layer  almost  completely  removed:  a,  lateral  vessels  ;  b,  seminal  vesicles;  c,  seminal  ducts;  d,  vas 
deferens:  g,  generative  glands;  h,  yolk  chambers  lying  in  the  cortical  layers;  i,  collecting  tubules  of 
yolk  chambers;  I,  conmiencement  of  uterus;  m,  coils  of  the  uterus  filled  with  eggs ;  n,  vagina ;  o, 
vaginal  opening. 

In  rare  instances  the  segments  of  the  taenia  solium  have  been  taken  into 
the  human  stomach,  either  by  being  swallowed  or  by  being  carried  back 
from  the  intestine  by  reverse  peristalsis.  In  such  cases  the  ova  are  set 
free  in  the  stomach,  the  embryos  develop  there  and  thence  pass  into 
the  blood  stream,  and  so  come  to  lodge  in  the 
tissues,  muscles,  brain,  skin,  etc.  Thus  man 
becomes  the  intermediary  host.  The  encysted 
embryo  or  cysticercus,  as  it  is  called,  then  forms 
an  elliptical  or  roundish,  transparent  vesicle,  from 
1  to  10  mm.  in  diameter.  In  its  interior  the 
characteristic  hooklets  may  be  seen. 

Bothriocephalus  latus  ordinarily  measures  from 
6  to  8  metres,  but  may  reach  a  length  of  15  to 
20  metres.  Its  head  is  shaped  like  a  bean,  and 
upon  its  flat  surface  are  two  grooves,  which  prob- 
ably act  as  suckers.  The  uterus  shows  from  four  to  six  convolutions 
on  each  side.    The  eggs  are  oval,  0.07  mm.  long  by  0.045  mm.  broad. 


Fig.  59 


Eggs  of  bothriocephalus 
latus;  the  one  to  the  right 
after  discharge  of  yolk. 
(After  Leuckart,  from 
Ziegler.) 


314  DISKASES  OF   THE   ALIMENTARY    TRACT 

Ki(i.  60  Fig  61 


1.  Oxyuris  vermicularis :  a,  male  ;  h,  female  ;  natural 
size.    2.  Maguified. 

Fig.  02 


Oxyuris  vermicularis :  a,  sexually 
mature  female  ;  6,  female  filled  with 
eggs  ;  c,  male.  Magnificatioa,  10.  (After 
Heller,  from  Ziegler.) 


Egg.s  of  o.xyuris  vermicularis  in  various  stages 
of  development :  a,  6,  c,  division  of  the  yolii ; 
d,  tad j)ole-like  embryo  ;  e,  worm-shaped  embryo. 
Magnification,  250.  (After  Zenker  and  Heller, 
from  Ziegler.) 


Fig.  63 


Fig.  64 


Ankylostoma  duodenale,  male    and  female. 
Natural  size.    (From  Mosler.) 


Eggs  of  ankylostoma  duodenale  :  a-d.  vari- 
ous stages  of  segmentation ;  e,  /,  eggs  con- 
taining embryos.  Magnification.  200.  (After 
Perroncito  and  Schulthess,  from  Ziegler.) 


INTESTINAL   PARASITES 


315 


The  larva  is  found  in  various  fishes,  especially  the  pike,  perch,  trout, 
and  turbot.  It  is,  therefore,  most  frequently  found  in  lake  regions.  The 
habitat  of  all  these  tape-worms  is  the  small  intestine  of  the  host.  There  is 
usually  but  one  worm,  but  two  or  more  have  been  met  w4th. 

Symptomatology. — There  are  no  distinctive  symptoms  of  the  presence 
of  a  tapeworm  in  the  intestine.  The  picking  at  the  nose,  restless  sleep, 
and  other  symptoms  popularly  ascribed  to  worms  are  symptomatic  only 
of  an  intestinal  indigestion,  and  may  come  from  overeating,  improper 
food,  etc.  Often  the  first  and  only  sign  of  the  presence  of  the  worm  is 
the  passage  of  some  of  the  segments.  In  other  cases  there  is  indigestion, 
w^ith  abdominal  discomfort  or  pain,  heavy  breath,  and  •  sometimes 
diarrhea.  Nervous  symptoms  are  seen  but  are  in  no  way  characteristic. 
The  bothriocephalus  latus  sometimes  produces  a  very  severe  anemia, 


Fig.  65 


Head  of  ankylostoma  duodenale :  a,  buccal  capsule  ;  b,  teeth  of  capsule  ;  c,  teeth  of  dorsal 
margin ;  d.  oral  cavity ;  e,  ventral  prominence ;  /,  muscle  layer  ;  g,  dorsal  groove  ;  h,  esophagus. 
(After  Schulthess,  from  Ziegler.) 

at  times  an  apparently  pernicious  anemia.  The  presence  of  tape-worm  is 
regularly  associated  with  a  moderate  eosinophilia. 

Diagnosis. — This  is  made  in  nearly  all  instances  by  the  segments  of 
the  worm  being  found  in  the  stools.  It  may  be  made  by  the  discovery 
of  the  eggs  in  the  stools  in  suspected  cases. 

Treatment. — This  is  usually  simple  and  the  result  satisfactory.  The 
child  is  given  a  light  supper  and  a  dose  of  castor  oil;  then  in  the  morning 
(fasting)  4  c.c.  (  1  drachm)  of  the  oleoresin  of  male  fern  is  given  in  four 
doses  of  1  c.c.  (15  minims)  each  (in  capsule)  at  hourly  intervals.  An 
hour  after  the  last  dose  a  full  dose  (a  tablespoonful)  of  castor  oil  is 
given.  The  worm  will  usually  be  passed  promptly.  Care  should  be 
taken  to  examine  the  segments  passed,  in  the  hope  of  finding  the  head. 
This  may  be  difiicult  to  do,  but  unless  the  head  is  found  we  cannot 


2.0  gm. 

(gr.  XXX). 

8.0  c.c. 

(3ij). 

4-8.0  gm. 

(5j-ij). 

30.0  c.c. 

(3j). 

316  DISEASES  OF   THE  ALIMENTARY   TRACT 

be  certain  of  a  cure.  If  it  remain.s  the  worm  will  tjrow  anew,  and 
after  two  or  three  iiionth.s  .seijnient.s  will  he  passed  again.  The  child 
mu.st  he  in  bed  during  thi.s  treatment. 

In  children  who  cannot  take  cap.sule.s,  1.5  to  2  c.c.  (20  to  30  minim.s) 
of  the  ethereal  extract  of  male  fern  may  be  given,  with  15  c.c.  (half 
an  ounce)  each  of  mucilage  of  tragacanth  and  water. 

If  male  fern  i.s  not  .succe.s.sful  kamala  may  be  given  with  it  in  the 
following  form: 

tl— Kamala 

Syr.  acaciae      ....  .       . 

Misce  et  adde 

Oleoresinae  filieis 

Aqufe  cinnamomi 

Sig.— To  be  taken  in  two  doses  with  an  interval  of  three  hours. 

Turpentine  can  be  given  in  thi.s  form: 

9— Olei  terebinth., 

Mellis ud    15.0  c.c.  (Sss). 

Mucilag.  acaciae q.  s.  ad    90.0  "  (3lij). 

Sig.— 8  c.c.  (two  teaspoonfuls)  every  six  hours.    Every  second  day  a  purge  of  castor  oil  should  be 
given  with  this. 

Kamala  may  be  given  in  honey  or  molasses,  4  gm.  (1  drachm),  for  a 
dose,  and  naphthalin  in  doses  of  0.12  gm.  (2  grains),  twice  a  day,  luis 
been  recommended. 

Ascaris  Lumbricoides. — The  ascaris  lumbricoides  or  round-worm  is 
the  most  frecjuently  found  intestinal  parasite  in  children.  It  is  a  cylin- 
drical worm,  looking  much  like  the  ordinary  large  angle-worm,  except 
that  the  body  is  somewhat  larger  and  the  extremities  more  pointed. 
The  head  consists  of  three  projections  or  lips,  which  are  provided  with 
fine  suckers  and  teeth.  The  male  measures  about  215  mm.,  the  female 
400  mm.  in  length.  The  tail  end  of  the  male  is  rolled  up  on  its  ventral 
surface  like  a  hook  and  provided  with  papilhie.  The  eggs  are  yellowish 
brown  in  color,  almost  round,  and  measure  O.OO  mm.  by  0.07  mm.  in 
size;  they  are  surrounded  by  an  irregular  albuminous  envelope,  which 
is  covered  by  a  tough  shell;  the  contents  are  coarsely  granular.  There 
are  regularly  more  than  one  of  these  worms  present,  and  there  may  be 
great  numbers,  so  that  the  worms  may  form  a  ma.ss  sufficient  to  obstruct 
the  intestine.  These  worms  are  great  wanderers.  They  mav  pass  into 
the  stomach  and  be  vomited;  they  may  crawl  out  of  the  nose  or  mouth, 
or  pass  out  by  way  of  the  Eustachian  tube  and  ear;  they  have  produced 
death  by  passing  into  the  larynx;  they  have  caused  jaundice  bv  obstruct- 
ing the  i)ile-duct,  and  have  been  known  to  produce  abscess  of  the  liver 
and  intestinal  ol)struction  or  appendicitis. 

Symptomatology.— The  symptoms  of  ascaris  infection  mav  be  none 
at  all,  the  worms  or  their  eggs  being  found  in  the  stools  accidentallv. 
In  other  cases  there  may  be  vague  digestive  disturbances,  such  as  are 
described  under  tape-worms.  These  worms  may,  as  noted  above,  pro- 
duce symptoms  l)y  their  mechanical  action.  Nervous  disorders  are  not 
uncommon  with  ascaris,  and  may  l)e  severe.     Among  these,  restlessness, 


INTESTINAL  PARASITES  317 

irritability,  sleeplessness,  grinding  the  teeth  at  night,  picking  the  nose, 
headache,  vertigo,  chorea,  and  even  convulsions  may  be  enumerated. 
In  these  conditions  the  presence  of  the  worms  in  the  intestine  seems  to 
act  as  a  reflex  excitant  of  the  nervous  system.  Some  observers  believe 
that  these  nervous  symptoms  are  produced  by  the  action  of  poisons 
produced  by  the  worms  in  the  intestine. 

Eosinophilia  is  observed  in  connection  with  the  presence  of  ascaris 
in  the  intestine. 

Diagnosis. — The  presence  of  round-worms  is  often  first  recognized 
by  the  passage  of  one  or  more  in  the  stools.  In  a  suspected  case  their 
presence  or  absence  can  be  determined  by  the  microscopic  examination 
of  the  stools  for  the  ova.  If  the  ascaris  is  present  the  ova  can  be  found 
in  large  numbers.  After  treatment  the  examination  should  be  repeated 
to  make  sure  that  all  the  worms  have  been  expelled.  The  presence  of 
an  eosinophilia,  not  otherwise  accounted  for,  should  lead  to  the  exami- 
nation of  the  feces  for  ova. 

Treatment. — Santonin  is  most  effective  and  is  most  easily  given.  It 
can  be  combined  with  calomel  to  advantage.  A  child  of  five  years  may 
be  given  from  0.18  to  0.36  gm.  (3  to  6  grains)  combined  with  an  equal 
amount  of  calomel.  The  medicine  is  best  given  in  the  morning  on  an 
empty  stomach.    It  may  be  ordered  in  the  following  form: 

{fc— Calomel, 

Santonin       . cZd    0.03  gm.  (gr.  ss). 

M.  et  fiant  trochisci  vi. 

Sig.— One  tablet  every  half-hour  until  all  are  taken. 

The  child  should  be  in  bed  during  the  day  of  treatment.  Usually 
several  worms  are  passed  after  such  medication.  If  the  examination  of 
the  feces  shows  that  worms  are  still  present,  the  treatment  may  be 
repeated.  It  should  be  remembered  that  the  administration  of  santonin 
is  sometimes  followed  by  visual  disturbances. 

Oxyuris  Vermicularis  or  Thread-worm. — These  are  minute,  thread- 
like worms,  the  male  being  4  mm.,  the  female  10  mm.  in  length.  The 
eggs  are  oval,  0.05  by  0.02  or  0.03  mm.  in  size,  and  covered  by  a 
membrane  with  a  double  or  triple  contour,  the  interior  being  coarsely 
granular.  The  female  worm  lives  in  the  cecum,  but  after  impregnation 
travels  down  to  the  rectum.  The  minute  worms  are  present  in  enormous 
numbers  in  the  rectum;  both  ova  and  worms  are  passed  in  the  feces 
and  are  found  about  the  anus,  on  the  genitals,  and  surrounding  parts. 
There  is  abundant  opportunity  for  a  child  to  infect  its  hands  and  so 
directly  reinfect  itself.  In  other  cases  infection  may  be  conveyed  indi- 
rectly through  the  agency  of  toys,  fruit,  etc.  Some  hold  that  the  whole 
life  cycle  of  the  oxyuris  may  be  completed  in  the  colon,  the  worm  finding 
favorable  conditions  in  the  mucous  coating  of  the  wall  of  the  colon. 
Other  authorities  deny  this  and  maintain  that  the  ova  must  be  swallowed 
and  the  embryos  developed  in  the  small  intestine. 

Symptomatology. — The  symptoms  produced  by  the  oxyuris  are  due 
to  the  local  irritation  of  their  presence.  They  may  excite  a  catarrhal 
colitis  or  proctitis,  with  the  production  of  much  mucus.     The  most 


31S 


DISEASES  OF   THE  ALIMENTARY   TRACT 


^'"••'^  distressing   symptom    is    usually   pruritus 

aui,  which  is  luuch  worse  at  uight,  due 
to  the  irritation  of  the  rectum  and  also  to 
the  fact  that  the  worms  at  that  time  pavss 
out  of  the  anus.  The  itching  leads  to 
scratching,  by  which  ulcers  may  he  pro- 
duced, (iisturbs  sleep,  renders  children 
peevish  and  irritable,  and  may  considera- 
l)lv  impair  their  general  health.  In  other 
cases  by  migrating  to  the  genitals  they 
])ro(luce  a  balanitis  in  the  male,  vulvitis 
or  vaginitis  in  the  female.  They  may  be 
a  cause  of  masturbation  in  either  sex. 
The  worms  have  also  been  found  in  the 
uterus,  in  the  appendix,  in  the  stomach, 
and  in  the  mouth. 

Diagnosis.— This  is  at  once  made  by  in- 
spection of  the  anal  region  or  of  the  stools. 
The  worms  are  usually  easily  found  in  the 
folds  of  the  anus. 

Treatment. — As   the    colon   and   rectum 
are  the  habitat  of  these  worms,  they  can- 
not be  well  treated  by  remedies  given  by 
mouth.      Injections    are    required    and   a 
great  variety  have  been  successfully  em- 
ployed.    Infusion  of  quassia,  salt  solution, 
8  gm.  to  240  c.c.  (2  drachms  to  8  ounces), 
or  a  solution    of    bichloride  of    mercury, 
1 :  5000  or  1 :  10,000.     The  bowels  should 
first  be  cleansed  by  an  enema  of  250  c.c. 
(half  a  pint)  of  water,  containing  4  gm. 
(1    drachm)    of    borax,    and     after    this 
has    been     passed     the    curative    enema 
should  be  injected  and   retained  for  one- 
half    hour.      These    injections    must    be 
repeated   every  other   night    for   a   week. 
This     treatment     may 
be  combined  with  the 
administration  of  san- 
tonin as  for  the  ascaris, 
for  the  purpose  of  bring- 
ing  down    any  worms 
which  may  be   lodged 
in   the  small  intestine. 

Male  of  ankylostoma  duodenale:   a,  head;  6,  esophagus  ;  c,  1  lie    treatment    IS    USU- 

gut;    d,  anal  glands  ;   e,  cervical  glands ;/,  skin  ;   ^.muscular  ally  promptly  cflFeCtive 

layer;  h,  excretory  pore;  t,  trilobed  bursa ;  A-,  ribs  of  bursa  ;  i,  I     V    f             +' "        +      +' 

seminal  duct;  m,  vesicula  seminalis;   n,  ductus  ejaculatorius ;  ^^^^^    irom    time  TO  lline 

o,  its  groove;  p,  penis;    q.  penile  sheath.     Magnification,  20.  casCS      are      met      with 
(After  Schulthess,  from  Ziegler.) 


INTESTINAL   PARASITES  3ig 

which  resist  all  treatment.     Holt  says  that  he  has  known  a  case  which 
had  resisted  all  other  treatment  for  two  years  to  be  promptly  cured  by 
injections  of  a  decoction  of  garlic  and  the  free  use  of  garlic  bv  mouth. 
Osier  mentions  the  case  of  a  man  who  suffered  from  childhood  until 
his  fortieth  year  from  these  parasites. 

For  the  itching  of  the  anal  region,  which  is  excited  by  these  parasites, 
the  application  of  vaselin  or  of  a  mercurial  ointment  may  be  tried. 

Ankylostomum  Duodenale  or  Uncinaria  Duodenalis  (Hook- 
worm).— This  small  worm  is  known  as  one  of  the  most  dangerous 
parasites  met  with  in  the  human  being.  It  has  long  been  known  to 
occur  in  various  parts  of  Europe,  Egypt,  and  the  West  Indies.  Within 
the  past  few  years  the  investigations  of  Stiles  have  shown  that  the 
parasite  can  be  found  in  large  numbers  of  the  children  in  our  Southern 
States  (Fig.  66). 

The  male  is  6  to  12  mm.  in  length;  the  female  10  to  18  mm.  The 
mouth  capsule  is  hollowed  out  and  surrounded  by  four  sharp  teeth, 
with  which  it  fastens  on  the  intestinal  wall.  The  eggs  are  oval  in  form, 
0.05  to  0.06  by  0.03  or  0.04  mm.  In  the  interior  of  the  egg  two  or  three 
segmenting  bodies  are  found  which  rapidly  develop  into  embryos 
outside  the  body,  so  that  after  twenty-four  to  forty-eight  hours  embryos 
may  be  found  in  the  same  feces  in  which  the  eggs  were  observed,  or 
fully  developed  ova  may  be  found  after  allowing  the  feces  to  stand  only 
a  few  hours  (Simon).  The  embryos  can  exist  for  as  nuich  as  thirty  days 
outside  the  body.  Infection  may  occur  directly,  but  is  probably  indirect 
in  most  instances  through  the  water,  or  such  articles  of  food  as  cresses, 
lettuce,  etc.  The  jejunum  is  the  habitat  of  the  parasite.  It  does  not 
remain  fixed  in  one  spot,  but  moves  from  place  to  place.  There  are 
usually  a  number  of  the  parasites  present,  as  many  as  1700  having  been 
counted  in  one  case. 

Symptomatology. — The  symptoms  of  hook-worm  disease  are  those  of 
a  grave  anemia.  The  children  are  pale  and  thin,  the  abdomen  protrudes ; 
they  suffer  from  edema  of  the  extremities,  shortness  of  breath,  and 
palpitation.  Many  of  them  are  mentally  dull,  languid,  and  backward; 
are  imfitted  for  school-life  and  unable  to  work.  The  habit  of  dirt-eating 
is  common  among  them.  They  have  notably  capricious  appetites;  the 
bowels  are  constipated,  and  the  stools  show  traces  of  blood  from  the 
hemorrhage  produced  by  the  parasites. 

According  to  Stiles'  investigations  infection  with  this  parasite  consti- 
tutes a  scourge  in  parts  of  the  Southern  States,  by  which  many  of  the 
children  are  condemned  to  lives  of  illness  and  uselessness. 

Diagnosis. — The  diagnosis  is  made  on  the  characteristic  appearance 
of  the  patients  and  the  examinations  of  the  stools  for  the  ova.  The  ova 
are  described  as  twenty  times  the  size  of  a  red  blood  corpuscle,  oval  in 
shape,  with  a  transparent,  colorless,  but  distinct  capsule,  and  a  gray 
or  brown,  segmental  protoplasm. 

Prognosis. — This  is  uniformly  good  under  appropriate  treatment. 

Treatment. — Male  fern  may  be  given  as  for  tape-worm,  but  thymol 
is  more  generally  employed  and  recommended.     It  is  to  be  given  in 


320  DISEASES  OF   THE   ALIMENTARY   TRACT 

capsules,  containinij:;  froni  2.5  to  4  gm.  (40  grains  to  1  drachm)  under  the 
same  conditions  as  any  other  anthehnintic.  No  solvent,  such  as  oil  or 
alcohol,  is  to  be  allowed  for  some  time  after  its  administration.  Serious 
symptoms  of  poisoning  have  appeared  in  some  cases,  but  the  results 
of  treatment  have  always  been  satisfactory.  The  anemia  is  to  be 
combated  with  iron. 


SECTION   V. 
DISEASES  OF  NUTllITION. 

By  GEORGE  M.  TUTTLE,  M.D. 


CHAPTER   XIV. 

RACHITIS— SCORBUTUS— MARASMUS. 
RACHITIS. 

Rachitis,  or  Rickets,  is  a  chronic  nutritional  disorder  of  the  whole 
organism.  Rachitis,  from  the  Greek  for  "the  spine,"  points  to  the  mis- 
taken idea  that  it  is  solely  a  disease  of  the  bones.  Modern  pathology, 
however,  teaches  quite  positively  that,  while  the  bone  lesions  may 
attract  the  most  attention,  the  muscles,  ligaments,  mucous  membranes, 
nervous  system,  some  of  the  viscera  and  the  blood  show  marked 
departures  from  normal.  As  a  matter  of  fact,  in  well-marked  cases  of 
the  disease  probably  every  tissue  and  organ  is  more  or  less  involved. 

Etiology. — With  relation  to  the  causative  factors  in  the  disease,  it  is 
agreed  that  the  error  is  a  dietetic  one,  but  beyond  this  we  cannot  advance 
so  surely. 

Rickets  is  rarely  seen  before  the  sixth  month  of  life,  is  most  common 
during  the  second  year,  and  only  its  results  are  seen  after  that  time. 
Virtually  no  new  cases  develop  after  a  child  has  been  well  fed  for  some 
months  on  a  more  or  less  general  diet,  and  in  children  having  the  disease 
it  spontaneously  disappears  under  these  same  circumstances. 

Rickets  develops  in  exclusively  breast-fed  babies,  in  babies  fed  on 
cows'  milk  variously  prepared,  and  especially  in  babies  fed  on  condensed 
milk  or  on  the  proprietary  foods;  so  that  no  one  form  of  food  can  be 
singled  out  as  the  cause  of  this  disease.  Originally  the  lack  of  lime-salts 
in  the  food  was  looked  on  as  causal,  in  the  days  when  the  osseous  lesions 
of  the  disease  only  were  recognized;  later,  the  absence  of  fat  and  again 
the  presence  of  lactic-acid-forming  elements  in  excess  were  considered 
of  the  greatest  importance. 

In  the  light  of  the  best  present  knowledge  of  the  physiological  chem- 
istry of  digestion  and  nutrition,  we  consider  the  deficiency  of  no  one  of 
21  (  321  ) 


322  DISEASES  OF  NUTRITION 

the  proximate  principles  in  the  food  of  so  much  moment  as  tliat  the 
food  .should  contain  all  the  main  in<:;redients  in  somewhat  nearly  the 
proportions  found  in  normal  average  human  milk.  To  he  more  exact, 
the  proteids,  with  their  chemically  combined  salts,  the  fats,  and  the 
carbohydrates  should  be  furnished  to  the  child  month  in  and  month 
out  in  the  ratio  designed  by  nature  to  supply  the  proper  quantity  and 
(juality  of  food  for  the  growing  organism. 

in  searching  for  the  cause  in  individual  cases  not  only  should  we 
know  what  food  the  baby  has  been  taking,  and  for  what  length  of  time, 
but  we  should  also  have  an  analysis  made  of  this  food.  We  will  ordi- 
narilv  find  some  striking  defect.  For  instan^-e,  when  rickets  is  seen  in 
breast-fed  babies  it  will  usually  be  found  that  lactation  has  been  unduly 
prolonged  until  the  combined  proteids  and  salts  have  become  quite 
deficient  in  nutrient  qualities,  or  the  mother  may  be  very  badly  nourished 
herself,  or  may  be  pregnant,  and  in  either  ca.sc  will  furnish  milk  showing 
on  analysis  decided  departures  from  normal. 

If  cows'  milk  is  the  food,  we  will  usually  find  the  milk  of  very  inferior 
quality,  or  wrongly  diluted,  or  excessively  sterilized. 

In  the  case  of  condensed-milk  feeding,  or  the  use  of  the  proprietary 
foods,  the  cause  is  more  evident,  as  these  foods  are  distinctly  lacking  in 
fats  and  ])roteids  and  contain  excessive  quantities  of  carbohydrates. 

^Yhile  the  dietetic  cause  is  all  important  in  the  development  of  rickets, 
and  we  see  cases  in  which  no  other  reason  for  the  disease  is  evident, 
still  we  cannot  overlook  the  fact  that  there  are  many  contributing  factors 
of  more  or  less  importance.  One  of  the  first  to  be  mentioned  is  racial. 
In  this  country,  at  least,  the  disease  is  more  frefjuent  among  the  negroes 
and  Italians,  probably  because  both  races  as  seen  in  our  large  cities 
are  badly  nourished  and  live  under  the  poorest  hygienic  conditions. 
For  years  rickets  was  called  "  the  English  disease,"  and  was  considered 
almost  a  curiosity  in  the  United  States.  But  with  the  great  massing  of 
people  in  the  large  cities  the  disease  has  become  very  common  among 
all  the  nationalities  represented  in  our  population,  even  the  native 
born. 

Rickets  is  far  more  common  among  the  poor,  the  ill-fed,  and  those 
living  in  unhygienic  homes  than  among  the  ])etter-housed  members  of 
the  community,  showing  the  marked  influence  of  fresh  air,  sunlight, 
and  dry  warmth  as  preventives.  There  is  no  reason  to  believe  that 
heredity  has  any  effect  in  causing  rickets,  nor  do  we  now  attach  any 
importance  to  syphilis  in  the  ancestry.  In  many  cases  it  would  appear 
that  digestive  disorders  have  some  etiological  relation  to  the  disease, 
and  while  they  are  the  cause  of  rickets  in  some  cases,  they  are  also 
frequently  the  result  of  this  disease. 

To  sum  up  the  above  analysis  of  the  important  causes  in  the  develop- 
ment of  rickets,  I  ascribe  most  importance  to  deficiency  of  the  fats,  the 
proteids,  and  the  salts  in  the  food,  and  far  less  moment  to  lack  of  fresh 
air,  sunlight,  and  warmth  in  the  homes  of  these  infants. 

Pathology, — The  most  evident  lesions  are  localized  in  the  bone.s. 
These  changes  are  seen  both  in  bones  formed  from  cartilage  and  in 


RACHITIS  323 

those  formed  in  periosteum.  They  consist  essentially  of  excessive 
proliferation  of  cartilage  cells,  or  of  hyperplasia  of  the  inner  layer  of 
the  periosteum,  combined  with  deficiency  of  the  normal  osseous  forma- 
tion which  should  follow  in  these  locations. 

In  bone  formed  from  cartilage,  at  the  epiphyseal  junctions  there  is 
increased  vascularity  of  the  parts,  with  swelling  and  thickening  of  the 
cartilaginous  layer.  The  matrix  of  the  cartilage  is  overcrowded  with 
cells  in  irregular  groups  of  disorderly  arrangement,  showing  no  dis- 
position to  lay  the  foundation  for  the  proper  histological  development 
of  the  future  bone.  In  addition  no  (or  only  abortive)  attempts  at 
calcification  of  these  cartilage  cells  are  seen.  There  is  very  little  deposit 
of  lime-salts  and  resultant  ossification,  and  the  growing  bone  is  soft, 
vielding,  excessively  vascular,  and  presents  many  of  the  appearances 
seen  in  inflammation.  The  bones  grow  in  diameter  by  the  proliferation 
and  subsequent  ossification  of  the  under  layer  of  the  periosteum.  Here, 
again,  somewhat  similar  changes  are  seen,  but  seldom  in  such  marked 
degree.  The  periosteal  cells  are  produced  in  excessive  amount,  but  do 
not  calcify  normally,  and  there  is  produced  a  soft,  spongy,  ill-formed 
bone.  Such  periosteum  is  grossly  quite  hyperemic,  and  strips  more 
easily  than  normal  from  the  underlying  bone.  As  the  bone  grows  in 
thickness  the  medullary  canal  becomes  formed  by  a  gradual  process 
of  absorption  of  the  inner  layers  of  newly  laid  bone.  This  absorp- 
tion process  goes  on  excessively  in  rickets;  so  we  have  a  bone  with 
spongy  wall  and  large  medullary  cavity,  and  hence  it  is  weak  and 
yielding. 

In  the  flat  bones  of  the  skull,  those  formed  in  membrane,  the  changes 
correspond  precisely  to  those  described  as  occurring  under  the  peri- 
osteum of  the  long  bones — hyperplasia  of  the  cells  of  the  under  layer  of 
the  membrane,  and  subsequently  imperfect  calcification  and  ossifica- 
tion. 

On  chemical  analysis  it  is  found  that  the  bones  from  a  case  of  rickets 
yield  two-thirds  organic  matter,  instead  of  the  average  one-third  of 
normal  bone,  showing  clearly  the  deficiency  in  the  mineral  ingredients. 

The  other  organs  than  the  bones  present  changes  not  of  such  a 
characteristic  nature,  but  still  showing  in  a  general  way  evidences  of 
malnutrition,  and  these  changes  are  as  important  from  a  clinical  as 
from  a  pathological  standpoint. 

The  blood  in  uncomplicated  cases  resembles  that  of  simple  anemia — 
the  red  cells  are  of  about  the  average  number,  but  each  cell  is  decidedly 
deficient  in  hemoglobin.  The  hemoglobin  index  is  usually  from  75  to 
50  per  cent.  Some  nucleated  red  cells  are  usually  found.  The  leuko- 
cytes tend  to  be  somewhat  above  their  normal  number.  In  cases  with 
severe  complications  of  a  pulmonary  or  gastroenteric  nature  the  marked 
changes  of  secondary  anemia  are  found — great  reduction  of  the  erythro- 
cytes combined  with  a  low  percentage  of  hemoglobin.  The  red  cells 
are  also  found  to  undergo  the  various  morphological  changes  character- 
istic of  this  condition.  More  or  less  leukocytosis  is  also  present,  due  to 
excess  of  lymphocytes  and  a  slight  eosinophilia. 


324  DI8EASI-JS  OF   XrTh'ITlOX 

The  heart  and  the  vohmtary  muscles  are  all  im])erfectly  nourished 
and  anemic,  siiaring  in  the  general  weakness  of  all  the  body  tissues. 
'^I'he  ligaments  hecoine  relaxed  and  weakened,  although  no  structural 
change  can  he  found  in  them. 

The  mucous  membranes,  both  of  the  respiratory  and  alimentary  tract, 
are  very  apt  to  show  catarrhal  inflammations,  which  are  considered 
secondary  to  the  rachitic  diathesis.  Whether  there  is  any  real  path- 
oloirical  chanjje  in  the  structure  of  the  mucous  luembranes  which  is 
responsible  for  the  marked  tendency  to  catarrhal  complications  in 
rickets  has  not  yet  been  discovered. 

The  lungs  in  aflvanced  cases  show  indentations  made  by  the  mal- 
formed or  collapsed  chest  wall,  due  to  a  mechanical  result  of  rickets. 

The  liver  lies  low  owing  to  the  diminished  chest  capacity,  and  is  often 
actually  somewhat  enlarged.  This  is  tlue  probably  to  a  passive  hyper- 
emia, which  in  prolonged  cases  may  be  followed  by  a  development  of 
new  connective-tissue  cells  with  some  hardening  of  the  organ.  The 
s})leen  is  regularly  enlarged  and  hyperemic,  and  may  undergo  the  same 
changes  as  the  liver.  Along  with  this  we  usually  find  the  lymph  nodes 
of  the  body  enlarged  and  hyperemic.  It  seems  that  they  are  specially 
liable  to  infections  from  any  slight  sources  of  irritation. 

Symptomatology. — It  must  be  remembered  that  rickets  is  a  chronic 
malnutrition,  slow  in  onset,  slow  in  development,  and  slow  in  recovery. 
Its  first  begiimings  are  often  unrecognized,  but  this  is  due  as  much 
to  neglect  to  look  for  the  early  signs  as  to  their  comparative  insig- 
nificance. 

One  of  the  first  signs  that  should  attract  attention  is  more  or  less 
anemia  in  an  otherwise  seenuno;lv  well-nourished  infant.  Alonj;  with 
this,  careful  examination  will  show  more  or  less  feebleness  of  the  mus- 
culature. Such  a  baby  will  make  no  effort  to  stand  on  what  appear  to 
be  well-developed  legs,  the  head  will  not  be  held  upright,  the  back  will  be 
bent  more  than  a  normal  baby's  in  sitting,  or  no  efforts  to  sit  up  will 
be  nutde.  The  whole  muscular  system  will  be  found  fiabby  as  compared 
with  that  of  a  normal  child  of  the  same  age.  With  this  there  will  usually 
be  a  history  of  constipation,  due  probal)ly  in  many  cases  to  weak  mus- 
cular action  in  the  intestinal  walls;  in  other  cases  it  is  the  result  of  the 
character  of  the  food. 

It  will  also  be  found  that  the  skin  is  soft  and  easily  irritated  and 
the  baby  sweats  a  great  deal  about  its  head  and  neck,  particularly 
during  sleep;  that  it  rolls  its  head  restlessly  about  on  the  pillow,  with 
the  result  of  almost  complete  baldness  in  the  occipital  region.  Its  sleep 
is  restless  and  l)roken,  and  there  is  more  or  less  general  "nervousness" 
present,  all  being  prol)ably  due  to  malnutrition  of  the  brain. 

As  the  disease  advances  the  above  signs  become  intensified,  and  in 
the  large  proportion  of  cases  there  are  added  the  more  characteristic 
changes  in  the  bones.  The  first  that  can  ordinarily  be  found  is  a  slight 
beading  of  the  ribs,  evident  only  on  palpation.  As  this  progresses  it 
takes  the  form  of  the  so-called  "rachitic  rosary,"  which  is  easily  evident 
to  the  eye.    The  "beads"  or  protuberances  are  due  to  the  pathological 


> 


PU 


RACHITIS  325 

hyperplasia,  characteristic  of  the  disease,  taking  place  at  the  costo- 
chondral  junctions  on  either  side  of  the  sternum.  They  are  found  at 
the  ends  of  the  ribs,  and  the  row  of  "beads"  runs  downward  and  out- 
ward along  the  costal  margin.  This  beading  is  also  present  on 
the  under  or  visceral  side  of  the  thorax,  but  naturally  can  only  be 
appreciated  here  postmortem. 

About  the  same  time  on  careful  examination  similar  changes  can  be 
found  at  the  epiphyseal  junctions  of  some  of  the  long  bones,  more  par- 
ticularly at  the  wrists,  ankles,  and  knees.  There  is  a  knob-like  enlarge- 
ment, palpable  in  the  early  stages,  visible  later,  which  lies  exactly  at  the 
point  where  epiphysis  and  diaphysis  join,  and  which  gradually  flattens 
down  to  the  level  of  the  bone  on  either  side  of  it.  Neither  the  "beads" 
nor  the  "knobs"  are  tender  to  pressure. 

The  head  appears  large  and  square.  The  forehead  is  high  and  broad 
and  the  top  of  the  head  is  more  or  less  flattened.  There  is  a  tendency  to 
a  shallow  furrow  along  the  line  of  the  coronal  and  sagittal  sutures.  These 
appearances  are  due  to  the  development  of  "bosses"  on  the  frontal  and 
parietal  eminences.  These  "bosses"  are  the  thickened  growths  of  bone 
characteristic  of  rachitic  pathological  changes  in  bones  developed  in 
membrane.  The  sutures  and  fontanels  are  large  and  regularly  late  in 
closing,  the  anterior  fontanel  being  often  open  at  the  end  of  the  second 
or  even  the  third  year.  The  veins  of  the  scalp  are  large  and  prominently 
blue  in  contrast  to  the  white  skin. 

Dentition  is  almost  always  delayed,  the  first  teeth  frequently  not 
appearing  until  after  the  first  year.  Then  they  are  often  cut  irregularly, 
"crossed  teething,"  and  frequently  decay  early.  The  various  disturb- 
ances ascribed  to  dentition  are  much  more  common  in  rachitic  children 
than  in  normal  ones. 

As  a  result  of  these  defectively  nourished  and  yiekling  bones,  various 
mechanical  changes  in  shape  and  form  follow,  some  the  result  of  atmo- 
spheric pressure,  others  of  muscular  action,  and  others  due  to  their 
inability  to  sustain  the  superincumbent  weight.  In  the  thorax  atmo- 
spheric pressure  produces  a  marked  depression  of  the  ribs  just  at  the 
costochondral  junction  and  parallel  to  the  sternum.  A  second  transverse 
groove  is  also  found  running  horizontally  around  the  lower  part  of  the 
chest.  Atmospheric  pressure  plus  diaphragmatic  pull  is  probably 
responsible  for  this.  The  sternum  itself  may  be  protruded,  or  may  be 
depressed,  producing  the  conditions  known  as  pigeon-breast. 

The  vertebrse  are  not  as  hard  as  normal,  the  ligaments  are  relaxed, 
and  the  muscular  support  is  deficient  in  tone,  resulting  in  a  bending  of 
the  spine.  The  kyphosis  or  scoliosis,  so  produced,  forms  a  long,  uniform 
curve,  with  none  of  the  sharp  angles  seen  in  tuberculous  disease  (Fig.  67). 
These  rachitic  curvatures  can  usually  be  made  to  disappear  by  gentle 
traction  or  change  in  position  during  the  disease  proper.  This  is  not 
true,  however,  of  the  resultant  bendings  that  may  remain  as  permanent 
deformities  after  the  rachitis  itself  is  past. 

In  the  posterior  or  lateral  regions  of  the  head,  more  often  over  the 
occipital  bone,  there  are  sometimes  found  softened  spots  of  imperfect 


326 


DISEASES  OF  NUTRITION 


bone  development  ealletl  craniotabes.  On  pressure  witli  tlie  tip  of  the 
finger  these  areas  dent  in,  but  spring  out  again  when  the  pressure  is 
released.     Craniotalu's  gives  to  the  finger  a  fec-Hng  of  crackhng. 

Secondary  changes  in  the  long  i)ones  regularly  develop,  especially  in 
the  legs.  These  may  result  in  bowing  outward  of  the  tibia^  and  femora, 
with  the  production  of  the  condition  known  as  l)ow-legs,  or  genu  varum; 
or  in  the  opposite  condition  of  knock-knees,  or  gcmi  valgum.  The 
former  seems  due  more  particularly  to  mechanical  bending  of  the  bones, 


Fig.  07 


Rachitic  kyphosis.    (Whitman.) 


while  the  latter  consists  mostly  of  an  hypertrophic  growth  and  consequent 
lengthening  of  the  inner  condyle  of  the  femur,  causing  the  tibia  to  make 
an  obtuse  angle  with  the  femur.  As  a  result  of  this,  when  the  child's 
thighs  are  placed  parallel  with  the  knees  together,  the  ankles  are 
separated  more  or  less  according  to  the  amount  of  the  knock-knee 
present. 

"When  the  bones  of  the  upper  extremity  become  bent,  the  humerus 
usually  bows  outward,  and  the  radius  and  ulna  backward.  In  severe 
cases  the  bones  are  so  softened  and  yielding  that  irregular  and  very 
distressing  deformities  may  develop  in  any  of  the  long  bones  (Figs.  68 
and  69). 


RACHITIS 


327 


In  the  pelvis  rachitic  changes  frequently  are  found,  but  they  always 
escape  notice  and  are  unimportant  except  in  women  at  the  time  of  labor. 
The  commonest  form  of  pelvic  deformity  of  rachitic  origin  is  a  shortening 
of  the  anteroposterior  diameter,  due  to  a  pushing  forward  of  the  body 
of  the  sacrum. 

The  ligaments  about  the  joints  are  more  or  less  relaxed  and  weakened, 
which,  in  combination  with  the  poorly  developed  muscles,  aids  in  the 
deformities  and  prevents  such  children  from  supporting  themselves  and 
walking  as  early  as  normal. 


Fig. 


Extreme  deformities,  the  result  of  infantile  rachitis.    The  left  leg  forms  practically  a  right  angle 
with  the  thigh.    (See  Fig.  69.)    (Whitman.) 


Rachitic  children  frequently  appear  fat  and  plump,  but  may  be  thin 
and  badly  nourished.  The  abdomen  is  enlarged  and  tympanitic,  for 
which  there  are  probably  two  reasons:  the  diminished  thoracic  cavity 
presses  down  the  diaphragm  and  crowds  the  abdominal  viscera,  and 
the  stomach  and  intestines  are  more  or  less  distended  as  the  result  of  a 
complicating  chronic  indigestion  and  weakened  muscular  walls.  There 
is  reo-ularlv  no  change  in  the  heart,  except  that  due  to  anemia  and  mal- 
nutrition, nor  in  the  temperature.     The  urine,  however,  may  present  an 


328 


DISEASES  OF  Xl'TRITIOX 


excess  of  phosphates  and  show  traces  of  albumin.    A  bruit  is  often  to  be 
heard  over  the  anterior  fontanel,  hut  this  is  of  no  special  significance. 

One  of  the  marked  characteristics  of  rachitic  children  is  their  tendency 
to  catarrhal  inflammations  of  the  gastroenteric  and  respiratory  tracts, 
and  to  reflex  c\])losions  of  their  nervous  systems.  So  we  frecpiently 
see  gastritis,  gastroenteritis,  chronic  indigestions  of  gastric  or  enteric 
origin;  laryngitis,  bronchitis,  or  bronchopneumonia;  and  hiryngisnuis 
stridulus,   tetany,   or  general   convulsions   developing   in    the    rachitic. 


Fi(..  i.'J 


Skiagram  of  Fig.  68,  showing  the  deformity  to  be  due  to  distortions  of  the  diaphyses  of  the  bones, 
while  the  epiphyses  are  practically  normal.    (Whitman.) 


Furthermore,  children  with  rickets  are  much  less  resistant  to  infection 
by  the  various  contagious  disciises  than  normal,  and  if  they  do  develop 
them  their  mortality  rate  is  higher  than  usual. 

Rickets  runs  a  course  of  one  to  two  years,  and  most  of  the  .symptoms 
disappear  spontanef)usly.  The  bone  changes,  however,  are  more  per- 
si.stent. 

Diagnosis. — In  the  early  stages  of  the  disease  and  in  mild  cases  it  is 
only  necessarv  to  have  rickets  in  mind,  so  as  not  to  overlook  it.  The 
presence  of  anemia,  mu.scular  weakness,  constij)ation,  delayed  dentition, 


RACHITIS  329 

orsweating  of  the  head  should  always  call  one's  attention  to  the  possibility 
of  the  beginning  of  rickets.  With  this  idea  in  mind,  a  careful  exami- 
nation of  the  bony  framework  will  usually  show  enough  to  corroborate 
the  diagnosis. 

Well-marked  cases  should  offer  no  difficulty  in  diagnosis,  except  that 
at  times  it  is  difficult  to  distinguish  the  cranial  changes  of  rachitis  from 
those  of  moderate  hydrocephalus.  In  the  latter  condition  the  forehead 
is  much  more  prominent  and  overhanging,  and  the  breadth  of  the 
whole  cranium  is  markedly  increased.  The  rachitic  enlargement  is 
mostly  due  to  the  thickening  of  the  bones  at  the  parietal  and  frontal 
bosses.  The  presence  of  other  rickety  changes  in  the  body  will  assist 
in  the  diagnosis,  as  well  as  the  backward  cerebral  development  present 
in  hydrocephalus.     The  two  diseases  may  coexist. 

The  various  lesions  of  congenital  syphilis  appear  much  earlier  than 
those  of  rickets,  and  the  later  bony  changes  are  not  so  regularly  con- 
fined to  the  epiphyseal  junctions  as  in  rachitis. 

In  chondrodystrophy  fetalis,  achondroplasia,  there  is  marked  short- 
ening of  the  long  bones  without  thickening  of  the  epiphyseal  cartilages. 

The  pseudoparalysis  of  rickets  is  easily  distinguished  from  real 
cerebral  or  spinal  paralysis  by  the  absence  of  any  changes  in  electric 
reaction,  or  in  the  superficial  reflexes. 

Scurvy  is  distinguished  by  the  hemorrhagic  gums,  the  painful  swelling 
in  the  shafts  of  the  bones,  and  the  prompt  benefit  following  antiscor- 
butic diet.  At  times  the  diseases  coexist,  but  the  relief  of  the  scurvy  will 
not  lessen  the  rachitic  evidences. 

Prognosis. — Rachitis  in  itself  is  seldom  if  ever  a  fatal  disease.  More 
than  this,  it  is  self-limited  and  regularly  recovers  of  itself  as  the  patient 
changes  by  degrees  from  the  limited  diet  of  infancy  to  the  more  general 
food  list  of  childhood.  The  osseous  deformities,  on  the  other  hand, 
which  have  resulted  from  the  malnutrition  of  the  rachitic  state  remain 
permanently  to  bear  their  witness  to  the  infantile  disease,  and  at  times, 
as  in  the  deformed  pelvis  of  a  pregnant  woman,  to  be  a  source  of  danger 
to  a  mother  and  an  unborn  child. 

But  while  rachitis  in  itself  can  be  considered  as  having  a  favorable 
prognosis,  it  is  indirectly  a  source  of  high  mortality  in  infancy  and  early 
childhood  from  its  complications.  Rickety  infants  are  specially  prone 
to  catarrhal  inflammations  of  the  respiratory  and  gastrointestinal  tracts, 
and  in  such  cases  frequently  die  when  a  healthy  child  would  recover. 
This  is  particularly  true  of  bronchitis,  bronchopneumonia,  or  whooping- 
cough,  and  also  of  gastroenteritis,  or  enterocolitis.  They  also  frequently 
die  in  an  attack  of  general  convulsions,  their  badly  nourished  nervous 
systems  seemingly  not  being  able  to  withstand  the  shock.  So  we  must 
not  make  light  of  any  manifestation  of  rachitis  when  it  is  present. 

Treatment. — Prophylaxis  is  of  great  import  in  this  condition,  and 
especially  so  when  by  careful  observation  we  become  convinced  that  the 
first  evidences  of  rickets  are  making  their  appearance.  Either  before 
such  appearance,  or  when  the  first  suggestion  of  symptoms  begins, 
every  precaution  should  be  taken  with  the  general  hygiene  and  the  food. 


330  DISEASES   OF  NUTRITION 

'V\\v  infant  should  live  and  slt'cp  in  wcll-v<>ntilated  and  sunsliiny  rooms, 
should  he  accustomed  to  daily  outings  in  the  fresh  air,  should  have 
regular  hatiiings  in  cool  water,  with  thorough  rubbings  afterward,  and 
should  be  warmly  clothed. 

More  important  than  these  is  a  careful  regulation  of  the  feeding. 
If  brea,st-fed,  the  mother's  milk  should  be  aiudyzed  and  efl'oi'ts  made 
to  remedy  any  deficiencies  present  in  it.  If  lactation  has  been  rather 
prolonged,  or  if  the  milk  cannot  be  im])roved  through  hygienic  measures 
directed  to  the  mother,  su})])lem(Mitary  feedings  of  a  suitable  food  for 
the  child's  age  should  be  given  in  addition  to  the  breast  milk,  and  these 
should  be  increased  in  number  even  to  the  com])lcte  weaning  from  the 
breast  in  case  of  need.  If  the  baby  is  artificially  fed,  a  careful  investiga- 
tion is  necessary  as  to  the  kind  of  food  given,  its  method  of  ])reparation, 
the  way  it  is  given  the  bal)y,  and  its  results  from  a  digestive  standpoint. 
Any  imperfections  in  one  or  more  of  these  particulars  should  be  at  once 
regulated,  and  the  results  carefully  watched.  In  short,  all  of  the  well- 
known  principles  of  the  modern  scientific  feeding  of  infants  and  children 
should  l)e  systematically  followed  in  these  cases. 

If  rachitis  has  already  positively  developed,  all  the  geniM'al  hygienic 
and  dietetic  measures  should  be  scrupulously  carried  out  in  their 
minutest  detail.  No  care  can  be  too  painstaking  in  attempting  promptly 
to  put  a  stop  to  the  symptoms  of  the  rachitic  malnutrition.  Fresh  air 
in  the  home  and  sleeping-rooms,  abundant  out-door  exercise,  cool 
bathing  and  massage  to  stinndate  the  respiration  and  circulation  and 
to  accustom  the  skin  to  changes  of  temperature,  and  so  prevent  the 
tendency  these  children  have  to  "catch  cold,"  are  all  of  great  impor- 
tance. 

The  diet  should  be  made  to  conform  as  nearly  as  possible  to  that 
suitable  for  a  baby  of  the  patient's  age.  Mother's  milk  may  need  to 
be  supplemented  by  one  or  more  daily  feedings  of  properly  modified 
cows'  milk.  Artificially  fed  babies  will  usually  be  found  to  be  getting 
condensed  milk,  or  one  of  the  proprietary  foods,  or  thoroughly  sterilized 
cows'  milk.  Any  of  these  foods  should  be  stop])ed  and  raw,  modified 
cows'  milk  substituted.  Some  babies  will  be  on  too  diluted  cows'  milk, 
not  offering  enough  solids  for  proper  nutrition,  and  others  still  on 
too  concentrated  cows'  milk  which  cannot  be  thoroughly  digested, 
starts  up  more  or  less  gastroenteric  indigestion,  and  is  never  assimi- 
lated. Others  are  too  early  fed  on  "table  food"  to  the  exclusion  of  milk, 
and  before  their  immatiu'c  digestive  organs  can  extract  the  proper 
nutriment  from  it.  It  is  possible  in  virtually  every  case  to  find  some 
gross  error  in  feeding  which  calls  for  instant  correction. 

The  general  principles  are  to  give  the  proteids  and  fats  up  to  their 
maximum  limit  of  digestion  and  absorption  and  to  keep  the  carbo- 
hydrates a  little  below  normal,  so  that  there  shall  be  a  more  perfect 
metabolism  of  the  former  two  proximate  principles,  as  they  are  the 
great  tissue  buiUlcrs.  The  regular  feedings  can  be  nicely  supplemented 
by  the  daily  use  of  beef-juice,  or  scraped  beef  or  mutton,  for  the  proteids, 
and  by  cream  or  butter  for  the  fats.    Any  of  these  substances  fulfil  the 


RACHITIS  331 

indications  of  easy  digestibility,  and  supply  an  abundance  of  proteids 
and  fats  very  satisfactorily. 

Much  more  than  half  the  battle  is  fought  by  hygiene  and  diet,  but 
drugs  are  more  or  less  helpful  and  certainly  should  be  used  except  under 
special  contraindications.  The  most  useful  drug,  and  the  one  which  is 
most  commonly  prescribed  is  cod-liver  oil.  But  if  we  analyze  its 
rationale,  we  at  once  conclude  that  even  in  this  case  we  are  giving  a 
food  rather  than  a  drug.  Cod-liver  oil  is  primarily  an  easily  absorbed 
fat,  and  so  is  especially  useful  in  rachitis.  It  undoubtedly  does  good, 
but  it  must  be  given  with  judgment  and  w4th  particular  attention  to 
the  digestion.  A  minimum  dose  rather  than  a  maximum  should  be  our 
aim,  and  on  the  least  evidence  of  any  gastric  or  intestinal  upset  it  should 
be  stopped  at  once,  and  when  resumed  the  dose  should  be  smaller  than 
before :  0.03  c.c.  to  1.5  c.c.  (5  to  20  drops)  three  times  daily  should  repre- 
sent the  dose  for  a  year-old  child.  Olive  oil  may  at  times  be  used  as 
a  substitute. 

Phosphorus  has  been,  and  is,  prescribed  extensively  in  the  treatment 
of  rickets  from  its  well-known  effect  in  stimulating  the  growth  and 
ossification  of  bone.  Its  use  has  the  sanction  of  many  well-known  men 
both  at  home  and  abroad.  If  given  judiciously  it  may  hurry  the  process 
of  recovery.  It  should  be  prescribed  in  doses  of  0.00032  gm.  to  0.00065 
gm.  {ywq  to  TTo  grain)  three  times  a  day.  Thompson's  solution,  con- 
taining 0.0032  gm.  to  4.0  c.c.  (yV  grain  to  the  drachm),  freshly 
prepared,  seems  to  me  to  be  the  most  satisfactory  preparation  to 
use. 

Lime  in  some  form  is  theoretically  given  to  furnish  more  lime-salts 
for  encouraging  the  calcification  of  the  bones.  Calcium  hypophosphite 
may  be  given,  or  the  precipitated  phosphate  of  calcium,  either  of  them 
in  doses  of  0.32  gm.  (5  grains)  three  times  a  day  mixed  with  the  food. 
Lime-water  is  of  no  direct  value  in  this  disease. 

The  anemia  should  be  treated  by  some  iron  preparation,  as  the  vinum 
ferri  amarum,  2.0  c.c.  to  4.0  c.c.  {h  drachm  to  1  drachm)  three  times 
a  day,  although  the  fresh  beef-juice,  not  beef-tea,  may  be  all  that  is 
necessary  in  combating  this  symptom.  In  the  use  of  any  or  all  of  these 
drugs  care  must  be  taken  not  to  upset  the  appetite  or  the  digestion  by 
them,  and  it  must  always  be  remembered  that  a  good  digestion  with 
proper  diet  and  hygiene  is  much  more  satisfactory  in  the  care  of 
rickets  than  any  other  therapeutic  measure. 

Complicating  conditions  must  be  met,  as  they  arise,  in  the  usual  way. 
Especial  attention  must  be  paid  to  any  digestive  troubles,  for  the  double 
reason  of  their  possible  danger  and  their  harmful  effect  on  the  rachitic 
process.  The  osseous  system  needs  attention  during  the  activity  of 
the  rachitis  to  prevent,  if  possible,  the  formation  of  bony  deformities. 
Much  can  be  done  by  care  in  keeping  the  child  in  proper  positions  both 
when  sitting  and  standing  to  prevent  permanent  kyphosis  or  scoliosis. 
Knock-knees  and  bow-legs  can  be  more  or  less  prevented  by  not  urging 
too  early  attempts  at  creeping  or  walking,  and  the  possibility  of  helping 
to  cause  bow-legs  by  too  bulky  diapers  should  always  be  kept  in  mind. 


332  DISEASES   OF  NUTRITION 

Often  tlio  use  of  light  supports  or  braces  inay  \w  of  distinc-t  advantage, 
but  should  be  supplemented  by  massage  and  passive  exercise. 

In  the  treatment  of  marked  deformities  due  to  a  pre-existent  rachitis 
the  case  should  be  considered  one  for  the  use  of  extreme  orthopedic  or 
surgical  measures.  I'he  results  of  rickets  in  the  pelvis  belong  to  the 
donuiiu  of  the  <)l)stetrieian. 


SCORBUTUS. 

This  disease,  of  recent  years  recognized  rather  frecpiently  among 
infants,  is  the  old-fashioned  sea-scurvy,  producetl  by  the  conditions  of 
modern  life  which  lead  to  the  necessity  for  the  frequent  artificial  feeding 
of  infants.  Scurvy  is  a  constitutional  malnutrition  characterized  mainly 
by  aneiiiia  and  a  general  hemorrhagic  tendency,  and  definitely  connected 
with  a  rather  prolonged  period  of  improper  feeding.  While  it  has  only 
been  recognized  properly  for  about  twenty  years,  as  occurring  in  infants, 
before  that  time  many  cases  were  reported  as  acute  rickets,  or  as 
hemorrhagic  periostitis,  or  under  other  names,  which  were  undoubtedly 
infantile  scori)utus.  Its  association  with  rachitis  in  the  same  child 
led  for  vears  to  nuich  confusion  in  diagnosis,  and  hence  to  imperfect 
classification. 

Etiology. — Infantile  scurvy  develops  wuth  greatest  frequency  from  the 
fourth  to  the  twenty-fourth  month  of  life.  An  occasional  case  is  seen 
before  the  fourth  month,  but  rarely,  as  the  conditions  leading  to  its 
development  recpiire  some  little  time  to  produce  the  scorbutic  symp- 
toms. After  the  second  year  cases  are  also  reported,  but  with  nuich 
less  frequency,  and,  of  course,  they  cannot  be  called  "infantile"  after 
that  time. 

It  is  in  the  large  proportion  of  cases  a  disease  of  the  middle  and  upper 
classes,  thus  contrasting  with  rachitis,  which  is  distinctively  a  disease 
of  poverty.  This  is  probably  explained  by  the  comparatively  small 
numl)(T  of  babies  among  the  poor  who  are  exclusively  bottle  fed,  and 
the  early  age  at  which  these  same  babies  begin  to  eat  solid  food  of  one 
kind  or  other,  particularly  potato,  which  is  recognized  as  one  of  the 
best  antiscorbutics.  On  the  other  hand,  infants  in  the  middle  and  upper 
walks  of  life  are  much  more  fre(|uently  bottle-fed  entirely,  and  often 
on  the  very  foods  which  are  most  prone  to  cause  scurvy. 

Previous  health  seems  to  have  very  little  bearing  on  the  disease,  nor 
does  the  presence  or  absence  of  good  hygienic  surroundings  influence  it. 
As  many  of  the  cases  develop  among  the  well-to-do,  naturally  the 
hygienic  environment  is  usually  above  the  average. 

In  studying  the  etiological  factors  diet  must  be  considered  first  and 
foremost,  and  as  a  matter  of  fact  this  is  the  only  actual  causative  agent. 
But  the  special  form  of  diet  used  previously  to  the  developinent  of 
symptoms  is  so  varied  and  so  beyond  classification,  that  it  is  difficult 
to  draw  definite  conclusions  which  will  convict  any  one  food  as  con- 
taining some  positively  harmful  element,  or  as  lacking  some  principle 


SCORBUTUS  333 

necessary  to  nutrition.  Even  what  is  ordinarily  considered  perfect 
infants'  food,  mothers'  milk,  has  some  few  cases  of  scurvy  charged  up 
against  it.  Raw  cows'  milk  must  be  put  in  the  same  category.  Sterilized, 
pasteurized,  or  peptonized  milk  has,  on  the  contrary,  each  many  cases 
to  its  credit.  A  few  cases  are  reported  as  developing  in  infants  fed  on 
"table  food,"  although  the  kinds  of  food  and  their  method  of  preparation 
are  unknown,  and  were  probably  entirely  unsuitable  for  babies.  The 
vast  majority  of  cases,  however,  give  the  history  of  having  been  fed  on 
some  one  of  the  proprietary  foods,  or  on  condensed  milk,  and  usually 
in  numbers  proportional  to  the  frequency  with  which  the  individual 
form  of  food  is  used.  This  looks  not  as  if  any  one  of  these  foods  was 
at  fault,  but  as  if  the  whole  class  of  "preserved"  or  "dead"  foods  lack 
something  necessary  to  prevent  scorbutus.  The  lack  of  the  quality 
which  is  best  called  freshness  seems  to  be  the  most  common  fault  in 
the  large  number  of  these  foods  which  are  responsible  for  the  great 
majority  of  the  cases.  Virtually  the  only  cases  in  which  this  is  not 
lacking  are  the  few  with  the  history  of  feeding  at  the  breast  or  on  raw 
cows'  milk.  For  these  it  is  difficult  to  make  any  explanation  except 
that  the  food  was  low  in  proteids. 

In  a  general  way  we  can  say  that  the  antiscorbutic  agent  is  something 
vital,  and  something  that  seems  to  be  destroyed  by  drying,  by  preserving, 
or  by  excessive  heating.  Probably  some  future  investigations  into  the 
biochemistry  of  foods  will  imravel  this  vexed  point,  determine  whether 
there  is  a  primary  intestinal  toxemia,  and  probably  find  the  exact 
element  necessary  to  prevent  the  development  of  scorbutus. 

For  the  present  we  must  adopt  the  conclusions  of  the  American 
Pediatric  Society's  collective  investigation  that  "scurvy  follows  the 
prolonged  employment  of  some  diet  unsuitable  to  the  individual  child," 
"that  there  are  certain  forms  of  diet  prone  to  be  followed  by  scurvy," 
and  "that  the  farther  a  food  is  removed  from  the  natural  food  of  a 
child  the  more  likely  is  its  use  to  be  followed  by  the  development  of 
scurvy." 

Pathology. — As  the  results  of  treatment  are  so  strikingly  successful, 
fatal  cases  are  rare  and  postmortem  examinations  more  so.  The  changes 
that  are  found  are  almost  all  those  due  to  hemorrhage  in  some  form  or 
other.  These  are  most  marked  under  the  periosteum  of  the  long  bones. 
A  hematoma  forms  there  and  strips  the  periosteum  from  the  bone, 
and  in  advanced  cases  causes  a  separation  of  epiphysis  from  diaphysis. 
For  some  reason  these  subperiosteal  hemorrhages  seem  more  common 
about  the  shaft  and  lower  end  of  the  femur  than  elsewhere,  but  simi- 
lar changes  occur  over  the  tibia  and  other  long  bones  as  well  as  on 
the  scapula  and  along  the  anterior  margin  of  the  ribs.  The  bone  in 
the  neighborhood  of  the  epiphysis  is  regularly  congested  and  hemor- 
rhagic. 

Hemorrhagic  spots  are  also  seen  in  the  pleura,  pericardium,  on  the 
liver,  or  other  viscera,  and  subcutaneously  in  almost  any  part  of  the 
body.  The  gums  are  swollen,  edematous,  and  hemorrhagic,  and  the 
teeth  are  frequently  loosened. 


334  i)isi:.\si:s  of  mtii'ITiox 

Symptomatology. — Onlinurily  the  infant  prcscMits  I'vidcnces  of  anoinia 
and  malnutrition  which  may  be  marked  enougli  to  attract  the  attention 
of  an  unskilled  observer,  but  in  some  cases  these  s'u^ns  can  be  dis- 
covered only  by  an  exjxTt.  As  the  same  general  imj)r()j)er  diet  that  is 
resjx)nsible  for  scurvy  is  also  causative  of  rickets,  we  may  find  evidences 
of  the  latter  form  of  malnutrition  present,  although  I  believe  that  there 
is  no  definite  connection  between  the  diseases,  and  scurvy  is  seen  in 
children  showing  not  the  least  sign  of  rickets.  In  the  past  the  two 
diseases  have  been  fre(juently  confused,  and  cvcmi  now  by  some  are 
considered  cognate,  although  the  only  real  reason  for  doing  so  is  that 
the  same  diet  may  cause  either  or  both  diseases.  We  must  rememl)er, 
too,  that  scurvy  is  essentially  a  chronic  disease  in  its  incej)tion,  and 
so  the  afflicted  infant  should  be  expected  to  show  more  or  less  mal- 
nourishment  before  the  characteristic  symptoms  appear. 

The  symptoms  show  themselves  first  usually  by  pain  and  tenderness. 
The  pain  may  be  spontaneous  and  present  even  when  the  child  is  at 
rest,  or  may  only  be  evoked  by  motion  or  handling.  The  little  patient 
often  screams  when  anyone  approaches,  as  if  in  dread  of  the  y)ossil)le 
pain,  or  when  any  motion  of  the  bed  is  made  that  shakes  him.  On 
examination  it  will  usually  be  found  that  this  tenderness  is  limited  to 
the  limbs,  more  commonly  the  lower,  and  that  motion  of  other  parts 
of  the  body  can  be  made  without  eliciting  the  symptom.  Occasionally 
the  spine  is  sensitive  and  tender. 

As  a  direct  result  of  this  tenderness  there  is  found  a  false  or  voluntary 
paralysis  of  the  limbs.  The  child  unconsciously  holds  them  quiet  to 
prevent  suffering.  This  so-called  paralysis  is  ordinarily  not  flaccid, 
but  spastic,  the  muscles  being  contracted  usually  in  flexion  and  in  the 
position  of  greatest  comfort,  and  it  can  be  easily  proved  that  no  true 
paralysis  is  present. 

The  same  limbs  may  also  shov/  what  is  really  the  most  characteristic 
sign  of  the  disease — marked  fusiform  swellings.  These  are  due  to  the 
subperiosteal  hemorrhages,  which  may  be  small  or  large,  and  single 
or  multiple.  They  are  ordinarily  in  the  epiphyseal  regions,  more  often 
of  the  femoral,  at  the  juncture  of  the  diaphysis  and  epiphysis,  and 
consequently  near  the  joints,  but  may  be  located  on  the  shafts  of  the 
long  bones.  The  skin  is  smooth  and  waxy,  very  seldom  bluish  or 
reddened.  In  severe  cases  there  may  l)e  a  separation  of  the  epiphysis 
and  hemorrhage  into  the  joint  with  the  signs  of  fracture  and  effusion. 

The  other  typical  symptom  of  scurvy  is  equally  frequent  and,  per- 
haps, even  more  common.  When  present  with  the  above  it  is  almost 
pathognomonic.  This  is  the  swelling  of  the  gums.  In  mild  cases  they 
are  only  swollen  and  brighter  in  color  than  usual  with  a  dark  reddish 
line  close  to  the  teeth,  but  in  more  advanced  stages  they  become  spongy, 
protuberant,  idcerated,  and  hemorrhagic.  When  teeth  are  present  the 
gums  are  more  seriously  involved,  but  many  cases  of  scorbutic  gingivitis 
have  been  reported  before  dentition  has  begun,  proving  that  teeth  are 
in  nowise  necessary  to  this  symptom.  The  hemoirhage  may  be  petechial 
in  the  cases  where  the  teeth  are  not  erupted. 


SCORBUTUS        .  335 

Hemorrhagic  conditions  elsewhere  are  also  frequently  to  be  found. 
Ecchymoses  of  the  subcutaneous  tissues  anywhere  on  the  body  are 
frequent,  the  common  location  being  in  the  loose  areolar  tissue  around 
about  the  orbit.  1'his  produces  a  "black  eye,"  or  a  protrusion  of  the 
eyeball  from  its  socket.  Ecchymotic  areas  on  the  thighs  and  legs  are 
also  seen  as  well  as  petechise.  Hemorrhages  from  one  or  other  of  the 
mucous  membranes  may  be  present,  as  from  the  mouth,  stomach, 
intestines,  or  nose.  Blood  or  albumin  without  erythrocytes  is  often 
found  in  the  urine. 

There  is  no  regular  fever  associated  with  this  disease,  but  irregular 
rises  of  temperature  may,  and  often  do,  occur,  even  in  the  absence  of 
complications. 

The  blood  shows  nothing  characteristic  beyond  the  regular  changes 
always  present  in  secondary  anemia.  I^eukocytosis  is  not  found  except 
as  resulting  from  some  complicating  condition.  All  grades  of  severity 
of  the  disease  are  encountered  from  simple  anemia  with  swollen  gums 
and  tender  limbs,  to  those  with  marked  degrees  of  hemorrhagic  gingivitis, 
large  subperiosteal  hemorrhages,  and  separation  of  the  epiphyses. 

Diagnosis. — Acute  articular  rheumatism  and  paralysis  are  often  diag- 
nosed when  scurvy  is  the  condition  present.  A  careful  examination  of 
the  gums  and  of  the  location  of  the  seemingly  swollen  joints  will  usually 
prevent  an  error.  The  swelling  of  scurvy  is  seldom  in  the  joint  proper, 
but  on  the  shaft  of  the  bone  at  the  junction  of  the  diaphysis  and  the 
epiphysis,  and  the  so-called  paralysis  can  easily  be  proven  not  real,  but 
an  immobility  due  to  pain.  Scurvy  has  been  mistaken  for  osteosarcoma, 
but  the  accompanying  symptoms  should  prevent  such  a  mistake,  and 
the  therapeutic  test  of  treatment  can  always  be  called  on  as  an  aid, 
and  should  be  tried  before  a  serious  operation  is  undertaken.  Inher- 
ited syphilis  occasionally  causes  a  separation  of  an  epiphysis  or  a 
pseudoparalysis  of  one  limb.     This  limitation  is  not  seen  in  scurvy. 

Recently  a  case  of  scurvy  with  subperiosteal  hemorrhage  has  been 
reported  as  operated  on  under  the  diagnosis  of  osteomyelitis.  Such 
error  would  be  unlikely  if  the  possibility  be  kept  in  mind,  and  an  exami- 
nation for  other  signs  of  scurvy,  together  with  dietetic  treatment,  would 
at  once  settle  the  question.  The  hemorrhages  from  the  intestine  should 
not  give  trouble  in  diagnosis  if  the  all-important  dietetic  factor  of  scor- 
butus is  considered.     The  same  may  be  said  of  blood  in  the  urine. 

Lead  poisoning  gives  symptoms  of  swollen  gums;  in  scurvy,  however, 
the  blue  line  found  in  lead  poisoning  is  absent. 

Prognosis.— This  is  very  good  if  the  disease  is  promptly  recognized 
and  properly  treated.  But  it  must  be  remembered  that  this  disease, 
unlike  rachitis,  is  not  self-curative,  but  is  progressive  and  chronic  in  its 
course,  and  so  tends  to  become  worse  as  time  advances. 

Unrecognized  cases  may  get  into  such  a  condition  of  malnutrition  and 
exhaustion  as  to  be  beyond  hope,  and  so  may  die  even  with  proper 
treatment  applied  late.  If  scurvy  attacks  a  child  already  weakened  by 
some  previous  disease  it  must  be  looked  on  as  influencing  the  prognosis 
unfavorably.     Pneumonia  is  likely  to  cause  death  in  untreated  cases. 


336  Dl;^EASES  OF  NUTRITION 

Treatment. — Prophylaxis  is  of  the  first  importance.  A  knowle(l<i;e  of 
the  etiology  of  infantile  scurvy  and  careful  attention  to  all  the  details  of 
the  correct  feeding  of  infants  should  absolutely  prevent  the  develo{)nient 
of  any  case  of  the  disease.  If  science  has  not  yet  taught  us  the  precise 
nature  of  the  etiological  factor  in  scorbutus,  she  has  taught  us  how 
easily  to  prevent  the  development  of  the  disease.  All  infants  who  are 
fed  artificially  should  have  some  fresh  unsterilized  cows'  milk  and 
orange-juice  three  or  four  times  a  week. 

If  the  disease  has  begun,  the  curative  treatment  becomes  necessary. 
This  is  entirely  dietetic  in  nature.  No  case  of  scurvy  has  ever  been 
reported  as  cured  by  drugs  only.  Since  so  many  different  ways  of 
feeding  have  at  one  time  or  another  been  responsible  for  cases  of  scurvy, 
the  first  rule  to  be  noted  is  that  a  change  of  diet  must  be  made.  At 
least  very  palpable  errors  must  be  corrected,  and  they  are  usually  so 
plain  that  it  requires  very  little  exact  knowledge  of  infant  feeding  to 
make  them.  Proprietary  foods,  condensed  milk,  sterilized  milk,  and  all 
"dead"  foods  must  be  at  once  discontinued.  Raw  cows'  milk,  properly 
modified  for  the  individual  baby,  is  ordinarily  the  most  proper  food  to 
substitute.  "^I'his  in  itself  will  usually  effect  a  cure,  as  it  contains  the 
antiscorbutic  property  in  moderate  amount.  But  other  substances 
contain  it  more  generously,  among  the  best  of  these  being  orange-juice, 
expressed  beef-juice,  and  potato.  The  first  two  can  be  easily  given  to 
babies  of  any  age,  the  potato  being  more  suited  to  the  treatment  of 
older  children.  But  it  even  can  be  given  to  quite  young  infants  if  it 
is  thought  advisable.  The  juice  of  a  whole  orange  can  be  given  daily 
to  a  baby,  antl  the  expressed  beef-juice  is  given  in  doses  of  a  table- 
spoonful  twice  daily.  Potatoes  are  prepared  by  thorough  steaming  and 
then  ma.shing  through  a  sieve.  They  can  be  given  dry  or  rubbed  up  with 
milk,  from  a  teaspoonful  to  a  tablcspoonful  two  or  three  times  daily, 
according  to  the  age  of  the  child.  In  infants  a  little  of  this  may  be  put 
in  the  bottle.  Under  such  dietetic  regimen  as  this  the  symptoms  may 
be  confidently  expected  to  improve  greatly  in  a  few  days,  and  complete 
cure  may  be  looked  for  in  three  or  four  weeks. 

The  child  should  be  k(>|>t  as  cjuiet  as  possible  to  protect  it  from  pain. 
The  swollen  limbs  should  be  wrapped  in  cotton,  and  kept  on  a  splint 
if  veiT  tender,  and  especially  if  the  epiphyses  have  separated.  I'he 
mouth  should  be  washed  clean  frequently  by  some  mild  antiseptic 
solution  to  prevent  bacterial  decomposition  in  the  secretions  of  the 
inflamed  gums. 

After  improvement  commences,  every  attention  should  be  paid  to 
building  up  the  baby's  nutrition  by  fresh  air,  proper  bathing,  massage, 
iron,  and  cod-liver  oil  if  necessary.  No  disease  presents  itself  where 
dietetic  treatment  is  more  satisfactory  if  properly  carried  out,  and  where 
the  results  of  our  therapeutic  efforts  can  be  used  as  an  aid  to  diagnosis 
with  such  confidence. 


MARASMUS  337 


MARASMUS. 


]\Iarasmus,  Infantile  Atrophy,  also  called  Athrepsia,  occurs  very  fre- 
quently among  infants.  Its  essential  feature  is  wasting,  and  this 
without  recognizable  or  gross  pathological  lesion. 

Various  organic  diseases  of  infancy  produce  the  same  resultant 
atrophy,  and  with  our  growing  improvements  in  diagnosis  we  are 
often  able  antemortem  to  find  such  a  cause ;  but  even  with  these  exclu- 
sions simple  atrophy  is  a  very  frequent  disease,  and,  more  than  that,  a 
very  frequent  cause  of  infantile  death.  jNIarasmus  could  be  best  defined 
as  emaciation  occurring  in  an  infant  without  discoverable  cause. 

Etiology. — Ifudoubtedly  more  than  one  element  is  concerned  in  the 
causation  of  this  disease.  In  many  cases  the  use  of  food  decidedly 
unsuited  to  the  child  in  quality,  quantity,  or  method  of  preparation  and 
feeding  explains  the  development  of  marasmus.  In  other  cases  markedly 
unhygienic  surroundings  are  the  cause,  and  more  often  yet  it  is  a  combi- 
nation of  the  two.  Frequently  it  is  easy  to  prove  the  presence  of  a 
decidedly  non -resistant  inherited  constitution,  and  in  any  case  it  is 
almost  impossible  to  say  that  this  vice  of  development  is  not  present. 

Further,  and  more  to  the  point,  marasmus  may  be  met  with  where 
neither  of  the  first  two  causes  is  at  work,  and  where  the  child  is  well 
fed  on  a  proper  diet,  and  lives  under  suitable  hygienic  conditions. 
It  is  in  these  cases  that  the  etiological  difficulties  present  themselves,  and 
we  are  compelled  to  seek  for  some  cause  of  a  more  subtle  nature  at 
work  in  an  infant  whose  resisting  powers  are  below  par. 

IMarasmus,  or  infantile  atrophy,  is  a  disease  of  the  first  year  of  life, 
or,  at  most,  of  the  early  part  of  the  second  year.  It  is  rare  among 
breast-fed  infants,  except  where  the  mother  is  so  overworked  and 
underfed  as  to  furnish  milk  of  most  inferior  quality,  but  is  commonest 
in  artificially  reared  babies,  and  especially  in  those  in  institutions. 
Indeed,  infantile  atrophy  might  well  be  classified  as  an  institutional 
disease.  In  private  practice,  especially  among  the  better  classes,  it  is 
almost  unknown.  A  long-continued  disturbance  of  digestion  bears  a 
causative  relationship  to  many  cases. 

No  investigations  have  been  able  to  associate  any  specific  micro- 
organism with  the  etiology  of  this  disease,  but  a  variety  of  different 
bacteria  are  found  in  the  intestinal  contents,  as  in  most  infants,  well  or  ill. 

The  disease  is  in  some  way  a  gastroenteric  infection  or  intoxication,  and 
that  it  has  the  power  of  being  conveyed  from  one  individual  to  another, 
as  is  seen  so  regularly  in  institutions  where  infants  are  kept  together. 
In  what  way  this  takes  place,  whether  through  the  air,  or  by  over- 
crowding, or  by  the  diapers,  or  by  the  handling  of  the  nurses  cannot  be 
decided,  but  precautions  should  be  taken  to  prevent  each  of  these  possible 
means  of  spreading  the  infection;  in  other  words,  the  prevention  of  the 
poison  of  "hospitalism." 

Pathology. — The  disease  seems  to  be  essentially  an  error  in  the  assim- 
ilative functions  of  the  digestive  tract,  and,  as  in  all  functiojigil  dis^ 
22 


338  DISEASES  OF  NUTRITION 

orders,  the  lesions  are  few  and  seemingly  unimportant.  Certain  observers 
report  a  selerosis  of  the  intestinal  mucous  niemhrane  with  atro{)hy 
of  the  glandular  substance.  There  is  hyperplasia  of  the  epithelial 
covering,  with  connective-tissue  infiltration  of  the  substance  of  the 
mucous  membrane.  In  areas  the  villi  and  glandular  layers  have  dis- 
appeared. The  mucosa  itself  is  in  places  thinner  than  normal.  The 
solitary  and  agminated  follicles  are  usually  enlarged  and  may  be  pig- 
mented, giving  the  so-called  "shaven-beard"  appearance  to  the  naked 
eye.  The  mesenteric  lymph  nodes  are  regularly  enlarged,  but  no  more 
so  than  in  children  dying  of  any  gastroenteric  disease.  In  some  cases 
none  of  these  microscojjic  nor  macroscopic  lesions  are  found,  showing 
that  they  are  in  nowise  typical  of  marasmus. 

The  results  of  the  marasmus  are  more  regularly  found.  The  body 
is  emaciated,  and  almost  free  from  subcutaneous  fat,  causing  the  skin 
to  lie  loosely  and  wrinkled  on  the  muscles.  Petechial  spots  and  larger 
subcutaneous  hemorrhages  are  quite  common.  The  liver  shows  fatty 
degeneration,  and  appears  enlarged  in  contrast  to  the  wasted  body. 
The  kidneys  frequently  are  the  seat  of  parenchymatous  degeneration. 
There  is  quite  regularly  more  or  less  hypostatic  pneumonia,  especially 
along  the  posterior  borders  of  the  lungs,  and  with  this  are  frequent  areas 
of  atelectasis.  The  heart  is  atrophied  and  pale.  The  stomach  is  often 
a  good  deal  dilated  and  its  lining  membrane  pale. 

While  these  lesions  represent  our  imperfect  knowledge  of  the  path- 
ological anatomy  of  marasmus,  its  functional  pathology  is  probably 
more  important,  but  in  many  ways  equally  vague.  It  is  sup{)oscd  that 
the  disorder  is  due  to  deficient  digestion  and  absorption  of  the  proteids 
and  somewhat  so  of  the  fats.  This  vice  of  assimilation  is  supposed  to 
result  from  the  lesions  of  the  mucous  membranes  already  described. 

Symptomatology. — The  disease  begins  almost  imperceptibly,  and  can 
only  be  detected  at  first  by  means  of  the  scales  at  the  weekly  weighings. 
It  progresses  in  the  same  gradual  way  as  it  began,  but  with  seemingly 
resistless  momentum.  Steady,  persistent  loss  of  weight  and  resultant 
emaciation  are  the  most  characteristic  features  of  marasmus  from 
bt^gimiing  to  end.  And  especially  is  this  failure  of  nutrition  typical 
when,  try  as  we  may,  no  evident  cause  for  it  is  to  be  found. 

The  infant  loses  its  previous  plump  appearance;  the  muscles  grow 
soft  and  flabby;  the  subcutaneous  fat  disappears,  leaving  the  skin 
wrinkled,  dry,  and  hanging  in  loose  folds  on  the  trunk  and  extremities. 
Over  the  abdomen  the  skin  can  often  be  ])ickcd  up  and  drawn  away 
from  the  underlying  fascia  in  much  the  same  way  as  is  done  by  the 
"elastic  skin"  men  of  the  dime  museum.  The  face  grows  thin,  pinched 
and  pale,  and  takes  on  the  characteristics  of  senility,  making  these  babies 
look  decidedly  like  little  old  men.  The  anterior  fontanel  is  sunken  and 
depressed,  and  shows  a  seemingly  exaggerated  pulsation.  While  every 
other  portion  of  the  body  wastes  until  it  seems  to  consist  only  of  the 
bony  framework  covered  with  skin,  the  abdomen  grows  more  prominent 
and  distended,  due  partly  to  the  enlarged  liver,  but  mainly  to  the  accumu- 
lation of  gas  inside  the  intestinal  canal. 


MARASMUS  339 

Anemia  is  marked,  but  has  only  the  characteristics  of  ordinary 
secondary  anemia  with  a  decided  fall  in  both  hemoglobin  and  red  cells. 
The  pulse  is  rapid  and  feeble,  and  the  breathing  shallow  and  insufficient. 
The  temperature  is  regularly  subnormal  even  in  the  rectum.  Rises 
of  temperature  occur  from  time  to  time,  but  are  usually  due  to  some 
temporary  intercurrent  trouble. 

The  tongue  is  coated  and  dry ;  the  mucous  membrane  of  the  mouth  is 
red  and  angry  looking,  and  often  shows  the  presence  of  the  thrush 
fungus.  The  appetite  is  regularly  enormous,  being  the  expression  of 
the  demand  of  the  starved  tissues  for  nourishment,  which  no  amount  of 
food  taken  into  the  stomach  seems  able  to  appease.  This  is  only  natural, 
as  filling  the  stomach  in  this  disease  does  not  mean  feeding  the  tissues. 
This  unnatural  appetite  leads  to  gastric  dilatation  and  rather  frequently 
to  attacks  of  vomiting,  the  stomach  being  kept  at  work  too  continuously 
for  its  weakened  state. 

The  bowels  may  be  constipated  or  may  be  loose.  Alternating  consti- 
pation and  diarrhea  are  fairly  common.  The  stools  regularly  contain 
undigested  food  particles,  are  green,  white,  brown,  rarely  yellow,  and 
have  a  most  offensive  odor  of  a  putrefactive  character.  This  odor  is 
very  far  reaching  and  tenacious,  and  rather  typically  present  in  this 
condition.  The  total  volume  of  fecal  matter  passed  is  rather  large,  as 
most  of  these  babies  eat  enormously  and  absorb  very  little. 

The  stools  seem  to  be  very  irritating  to  the  malnourished  skin,  and 
we  regularly  find  the  buttocks  excoriated  and  red;  and  bed-sores  may 
develop  over  the  sacrum,  occiput,  heels,  and  at  times  over  the  ears. 
The  child  usually  lies  in  one  position,  dozing  much  of  the  time,  always 
sucking  its  thumb  or  fingers,  frequently  until  the  skin  becomes  excoriated, 
and  noticing  very  little  that  goes  on  round  about  it.  If  disturbed,  or 
if  its  fingers  are  taken  out  of  its  mouth,  it  frets  and  whines  until  fed 
or  left  alone  again  to  its  favorite  habit.  Some  infants  whine  continu- 
ously, and  are  evidently  in  persistent  discomfort. 

Nervous  symptoms,  misnamed  hydrocephalus,  may  develop;  twitch- 
ings,  rolling  of  the  eyeballs,  picking  at  objects  (as  the  bed-clothes),  and 
even  convulsions  may  occur.    The  neck  may  be  retracted  and  stiff. 

The  tendency  of  the  disease  is  regularly  onward  toward  a  fatal 
termination.  This  comes  most  often  from  exhaustion  with  a  very  low 
temperature.  At  other  times  it  is  due  to  a  general  convulsion,  but  quite 
frecjuently  is  the  result  of  some  intercurrent  disease.  In  the  rare  cases 
of  recovery  improvement  is  very  slow,  and  months  are  often  taken 
before  the  tissues  seem  to  regain  their  proper  tone. 

Diagnosis. — This  depends  almost  entirely  on  our  ability  to  exclude 
all  forms  of  organic  disease.  In  the  first  place  we  must  be  sure  that 
there  is  no  possibility  of  the  presence  of  active  or  latent  tuberculosis. 
Of  course,  the  discovery  of  a  local  focus  of  tuberculosis  in  lymph  nodes, 
lungs,  bones,  or  meninges  would  at  once  put  us  on  the  right  track,  but 
it  must  be  remembered  that  the  lymph  nodes  often  enlarge,  and  that 
atelectatic  or  congested  spots  often  form  in  the  lungs  in  marasmus, 
which  may  be  decidedly  confusing.  Fever  ordinarily  accompanies  any 
form  of  tuberculosis,  while  it  is  absent  in  uncomplicated  marasmus. 


340  DISEASES  OF  XVTIUTIOX 

Progressive  wasting  is  not  so  cliaracteristic  of  tuberculosis  in  infancy 
as  is  commonly  supposed.  At  that  time  of  life  tuberculosis  is,  in  most 
cases,  of  the  general  miliary  type, and  is  fpiickly  fatal,  with  rapid  wasting 
perhaps,  but  not  with  the  slowly  progressive  loss  of  flesh  characteristic 
of  infantile  atrophy. 

Chronic  gastroenteric  catarrh  has  many  of  the  same  symptoms  as 
marasmus,  and  at  times  the  diflFerential  diagnosis  will  be  very  difficult. 
The  history  of  the  beginning  of  the  two  diseases  is  different,  however, 
and  a  careful  study  of  the  action  of  the  stomach  and  intestines,  together 
with  critical  scrutiny  of  the  stools,  will  aid  in  the  diagnosis. 

In  hereditary  syphilis  wasting  is  often  present,  but  again  the  history 
of  early  coryza,  rashes  on  the  skin,  and  mucous  patches  at  the  muco- 
cutaneous junctioti  will  assist.  The  effects  of  treatment  with  anti- 
syphilitics  will  l)e  of  value  here. 

Prognosis. — Under  any  circumstances  marasmus  is  a  very  serious 
disease.  In  institutions  it  is  almost  invariably  fatal.  It  is  possibly  less 
so  among  the  poor  and  ignorant  in  their  homes,  and  somewhat  less  so 
when  occurring  among  people  in  better  conditions  of  life.  But  even  here 
where  directions  can  and  will  be  intelligently  carried  out,  and  evers'thing 
that  is  needed  can  be  procured,  it  is  often  very  difficult  to  get  the  infant's 
nutrition  started  on  the  up  grade.  If  once  this  beginning  is  made,  the 
cure  follows  by  a  \evy  gradual  gain  in  weight  week  by  week,  and  a  slow 
return  of  all  the  tissues  to  a  proper  degree  of  nutrition. 

\Mien  recovery  does  occur  the  infant  returns  absolutely  to  normal, 
and  no  results  of  the  disease  are  left  behind. 

Treatment. — The  first  important  point  in  treating  this  disease  is  to 
change  and  improve  the  surroundings  in  which  the  baby  has  been 
living.  For  instance,  an  infant  in  an  institution  or  hospital  that  has 
developed  marasmus  has  many  more  chances  for  recovery  if  sent  out 
into  a  private  home,  and  often  when  this  home  has  not  all  of  the  so-called 
best  sanitary  surroundings,  than  if  kept  at  the  institution  with  a  number 
of  other  children.  The  f[uiet  and  the  individual  care,  and  the  absence 
of  what  has  been  called  for  want  of  a  better  name  "hospitalism,"  serve 
to  comi)ine  for  better  results  than  continued  life  in  the  institution,  no 
matter  how  carefully  that  is  watched.  In  a  similar  way  a  child  in  a 
well-conducted  home  will  often  be  benefited  by  a  change  of  air,  such  as 
would  be  found  in  a  different  climate. 

The  infant  should  be  given  an  abundance  of  fresh  air;  should 
have  regular  daily  massage,  bathings,  and  alcohol  rubs,  which  should 
be  ended  by  a  cool  douche  to  stimulate  respiration;  its  position  in 
bed  should  be  frequently  changed  to  prevent  hypostatic  congestion  or 
formation  of  pressure  sores;  its  mouth  shouhl  be  frequently  washed 
out  with  saturatofl  boric  acid  solution  or  other  mild  antiseptic,  to  pre- 
vent the  development  of  thrush  or  other  form  of  stomatitis;  its  diapers 
should  be  changed  at  once,  whenever  wet  or  soiled,  to  save  the  skin 
of  the  l)uttocks  and  neighboring  parts  from  irritation,  and  to  pre- 
vent the  possibility  of  a  further  fresh  infection  through  the  stools. 
If  thru>h,  intertrigo,  or  bed-sores  have  developed  they  should  be 
treated  in  the  ordinary  manner  with  great   promptness  and  care,  a^ 


AIARASMUS  341 

any  form  of  complication,  be  it  ever  so  mild,  retards  the  chances  for 
recovery. 

Of  greater  importance,  but  not  so  much  so  that  the  above  points 
can  in  any  way  be  neglected  or  overlooked  (for  the  greatest  attention 
must  be  paid  to  every  little  detail  to  accomplish  results  in  this  disease), 
is  the  condition  of  the  digestive  tract  and  the  system  of  feeding.  The 
digestive  canal  must  be  thoroughly  cleaned  out  to  remove  any  possible 
bacterial  poisons  or  toxin  irritants  that  may  be  hindering  the  proper 
assimilation  of  the  food.  Calomel  in  0.006  gm.  (yV  grain)  doses  every 
hour  for  ten  doses,  or  a  teaspoonful  of  castor  oil,  seem  to  do  this  most 
thoroughly.  After  either  has  acted,  a  thorough  washing  of  the  colon  by 
means  of  a  soft -rubber  catheter,  of  No.  8  to  10  French,  passed  high 
in  the  rectum,  using  warm  normal  salt  solution  and  allowing  it  to  flow 
in  and  out  until  the  fluid  returns  clear,  is  the  next  procedure  in  order. 
These  two  therapeutic  measures  may  often  be  advantageously  repeated 
every  three  or  four  days.  By  these  means  we  often  can  put  the  intestinal 
absorbents  in  a  condition  of  readiness  to  take  up  and  carry  into  the 
system  a  properly  prepared  nutriment,  which  it  is  our  next  effort  to 
offer  them. 

The  actual  feeding  problem  is  a  very  difficult  one,  and  each  case  must 
be  a  law  to  itself,  as  no  two  cases  will  give  the  history  of  the  same  kind 
of  previous  feeding,  or  of  the  same  results  of  that  feeding.  On  general 
principles  it  will  usually  be  easy  to  find  some  palpable  error,  or  more 
likely  errors,  in  the  feeding  method  in  use.  The  simple  fact  that  the 
baby  has  become  marantic  on  a  given  food  is  evidence  enough  of  the 
necessity  for  a  change. 

In  the  rare  case  where  the  infant  is  at  the  breast  a  careful  study  of 
the  mother's  milk  must  be  made,  and  if  defective  this  must  be  replaced 
by  that  of  a  proper  wet-nurse,  or  supplemented  by  artificial  feedings  of 
some  food  that  supplies  the  deficiencies  found  in  the  breast  milk. 

In  the  more  common  case  of  the  artificially  fed  infant  we  will  usually 
find  that  the  demands  of  the  infant's  abnormal  appetite  have  been 
supplied  by  a  very  excessive  quantity  and  an  altogether  too  rich  quality 
of  food,  certainly  by  one  which  this  particular  marantic  infant  can  in 
nowise  digest  properly  or  absorb  properly,  and  the  unoxidized  remnants 
of  which  only  act  as  poisonous  irritants  and  splendid  culture  media  for 
the  large  number  of  intestinal  bacteria  which  are  always  ready  to  enact 
their  life  processes,  much  to  the  detriment  of  their  host.  Indeed,  too 
much  food  is  the  usual  mistake  which  we  must  correct.  The  quantity 
must  be  governed  by  the  powers  of  the  intestinal  absorbents  and  not  by 
the  seeming  demands  of  the  baby's  appetite.  The  baby's  weight  rather 
than  its  age  should  be  considered  in  deciding  on  the  quantity  of  food  to 
be  administered,  and  only  so  much  given  as  seems  to  be  properly  taken 
care  of  by  the  digestive  and  absorptive  systems. 

The  rule  is,  therefore,  to  begin  treatment  by  a  minimum  quantity  and 
dilute  quality  of  food,  very  cautiously  adding  to  both  as  the  story  of 
the  stools  and  the  baby's  weight  tell  us  the  time  is  ready.  The  point  to 
be  sure  of  is  that  complete  assimilation  of  what  is  given  is  taking  place 
before  adding  more.     This  food  should  be,  to  begin  with,  carefully 


342  DISEASES  OF  WTRITION 

modified  cows'  milk,  as  fresh  and  free  from  bacterial  or  other  con- 
tamination as  can  possil)ly  l)e  obtained.  It  had  better  be  fed  raw 
unless  the  season  of  the  year  or  other  accidental  cause  should  decidedly 
contraindicate.  As  diluent,  the  consensus  of  opinion  seems  to  be 
ilecidedly  in  favor  of  cereal  decoctions  as  especially  valuable  in  this 
disease. 

The  casein  percentage  should  be  kept  very  low,  but  the  soluble 
proteid  percentacje  can  l)e  proportionately  raised  by  the  use  of  whey 
mixtures,  as  will  be  found  in  other  parts  of  this  work.  (See  p.  100.)  Hut 
it  nmst  l)e  remembered  that  the  proteids  are  our  best  tissue  builder, 
and  tentatively  more  and  more  nmst  be  <i;radually  added  to  the  fo(jd 
as  the  digestion  can  take  care  of  them,  or  gain  in  weight  will  be  very 
slow.  The  total  proteids  should  be  from  1  to  1.50  per  cent.  AVhey  is 
often  a  satisfactory  food  if  not  continued  for  too  long  a  time. 

'i'he  fats  ai'c  quite  likely  to  i)e  undigested  in  this  disease,  and  must 
be  also  used  with  great  caution  and  in  small  amount,  until  the  digestion 
gradually  accommodates  itself  to  their  increase,  which  again  must  be 
slow.  The  fat  should  be  from  0.5  to  2  per  cent.  The  yolk  of  egg  in 
small  quantity  may  l)e  tried  in  some  cases  with  advantage. 

There  seems  to  be  no  special  necessity  for  reducing  the  sugar  below 
the  ordinary  0  to  7  per  cent.,  and,  as  a  rule,  there  seems  no  advantage 
in  the  use  of  one  form  of  sugar  over  another.  Cane-sugar  or  lactose  may 
be  used  indiscriminately  uidess  cane-sugar  occasions  fermentation. 
The  addition  of  a  few  grains  of  sodiiun  chloride  to  each  feeding  seems 
to  be  of  some  value  in  assisting  in  the  osmosis  of  the  food. 

In  some  cases  the  use  of  a  wet-nurse  until  the  baby  obtains  its  first 
start  on  an  improved  nutrition  is  an  absolute  necessity,  as  often  these 
infants  cannot  digest  any  modification  of  cows'  milk. 

(iavage  may  l)e  re(juire<l  in  the  feeding  of  l)al)ies  who  are  very  weak. 

In  all  cases  careful  study  of  the  character  of  the  stools  themselves, 
of  their  volume  proportionate  to  the  food  taken,  and  of  their  frequency 
or  infrequency,  combined  with  daily  weighings  on  correct  scales,  gives 
us  our  knowledge  of  the  condition  of  the  digestion  and  assimilation, 
which  is  to  guide  us  in  our  further  dietetic  and  therapeutic  procedures. 

Drugs  are  unimportant  in  treating  marasmus,  but  may  be  useful 
adjuncts  in  dealing  with  many  of  the  accompanying  symptoms.  The 
use  of  nux  vomica  alone,  or  combined  with  dilute  hydrochloric  acid  may 
give  a  tone  and  stimulus  to  the  digestive  canal  which  will  aid  it  in  the 
work  asked  of  it.  A  constipated  baby  will  gain  faster  than  a  baby  with 
diarrhea;  so  we  would  rather  these  infants  do  not  have  too  loose  bowels. 
If  this  looseness  is  present  and  is  due  to  unabsorbed  food  remnants,  its 
correction  should  be  dietetic,  but  if  due  to  excessive  peristalsis  a  little 
opium  may  be  of  value. 

P^xcessive  restlessness  and  fretfulness  and  insomnia  may  be  helped 
by  a  little  bromide  or  chloral.  \'omiting  is  treated  by  dietetic  measures, 
and  often  by  lavage.  The  use  of  iron,  cod-liver  oil,  or  other  "tonics" 
is  best  left  until  the  convalescent  stage,  when  they  can  be  added  to 
the  dietetic  procedures. 


SECTION  VI. 
INFECTIOUS  DISEASES. 

By  ISAAC  A.  ABT,  M.D.;  DAVID  BOVAIRD,  Jr.,  M.D.  ;  D.  J.  McCARTHY,  M.D.; 

MATTHIAS  NICOLL,  Jr.,  M.D.;  JOHN  RUHRAH,  M.D.;  FLOYD 

M.  CRANDALL,  M.D.,  and  GEORGE  U.  TUTTLE,  M.D. 


CHAPTER  XV. 

TUBERCULOSIS. 

THE  TUBERCLE  BACILLUS   AND  THE  TUBERCLE. 

By  ISAAC  A.  ABT,  M.D. 

The  tubercle  bacillus  appears  in  the  tissues  as  a  short,  slender  rod, 
2  to  5//  in  length.  Most  recent  investigators  believe  that  it  is  properly 
classified  with  the  streptothrices,  not  with  the  bacteria,  because  of  its 
tendency  to  produce  branching  forms  in  culture  media.  It  belongs  to 
a  group  of  acid-proof,  alcohol-proof  organisms;  that  is,  these  organisms 
when  deeply  stained  with  aniline  dyes  by  prolonged  immersion,  or  by 
heating,  do  not  lose  their  color  on  the  application  of  mineral  acids  or 
alcohol.  In  the  bodies  of  the  bacilli  are  often  seen  both  unstained 
portions  (vacuoles)  and  especially  deeply  stained  (metachromatic) 
granules.  Both  of  these  have  been  supposed  to  be  spores,  but  this  view 
has  become  generally  discredited,  since  tubercle  bacilli  are  killed  in  a 
few  minutes  by  a  temperature  of  70°  C.  (158°  F.).  Especially  char- 
acteristic is  their  very  slow  growth  on  all  culture  media  and  their  difficult 
development  at  high  or  low  temperatures — range  29°  to  40°  C.  (84°  to 
104°  F.).  The  latter  factor  makes  the  organism  strictly  parasitic;  it 
does  not  multiply  except  in  the  animal  body.  Dried  sputum  retains  its 
virulence  for  from  three  to  four  months ;  sunlight  or  any  of  the  ordinary 
antiseptics  destroys  the  bacilli,  if  sufficiently  exposed. 

The  localization  of  the  tubercle  bacillus  in  the  tissues  is  followed  by 
very  characteristic  pathological  changes.  The  most  im.portant  is  the 
production  of  tubercles.  These  are  small  nodules,  produced  by  pro- 
liferation of  connective  tissue  and  a  moderate  emigration  of  leukocytes. 
The  nodules  in  the  course  of  their  development  undergo  caseation  in 
their  centres.    Microscopically,  the  changes  are  exactly  alike,  no  matter 

(343) 


344  INFECTIOUS  DISEASES 

what  part  of  the  body  may  he  affected.  A  fully  developed  tubercle 
presents  the  follownig  appearance:  in  its  centre  is  an  area  of  necrotic 
tissue,  at  the  periphery  of  which  a  variable  number  of  giant  cells  are 
Usually  found.  Each  giant  cell  consists  of  a  large  mass  of  degenerated 
protoi)lasm  with  five  to  twenty  nuclei  at  its  border.  The  necrotic  tissue 
is  surrounded  by  a  wall  of  epithelioid  cells,  these  in  turn  by  round 
cells.  Beyond  the  round  cells  is  a  layer  of  mature  connective  tissue. 
If  this  layer  is  complete,  the  tubercle  is  said  to  be  encapsulated,  and 
under  the  circumstances  considered  healed.  Often  lime-salts  are 
deposited  in  a  tubercle;  it  is  then  said  to  be  calcified.  Bacilli  are  found 
in  greatest  numi)er  in  young,  growing  tubercles.  In  older  ones  they  are 
usually  few  in  number  and  appear  in  the  periphery  of  the  necrotic 
tissue  and  in  the  giant  cells.  If  the  tubercle  attains  a  large  size,  as  in 
the  lung,  the  necrotic  area  becomes  very  soft  and  finally  liquefies 
and  forms  a  tulxn'culous  cavity.  It  is  a  peculiar  fact  in  the  pathology  of 
tubercle  that  capillaries  do  not  tend  to  regenerate.  Caseation  in  older 
lesions  may  be  explained  in  part  by  the  diminished  vascularity  of  the 
tissues.  The  tubercle  bacillus  and  its  toxins  are  the  exciting  factors 
in  the  degeneration.     (See  Plate  VII.) 

Localization  of  Tubercles. — No  tissue  or  organ  of  the  body  is  immune 
from  tuberculous  invasion.  Bloodvessels  are  seldom  involved;  indeed, 
so  rarely  have  they  been  found  affected  that  for  a  long  time  it  was 
believed  that  they  presented  an  immunity  from  infection.  The  foregoing 
belief  had  some  foundation  in  fact,  since  large  vessels  may  remain  free 
from  attack,  at  times  a  large  bloodvessel  being  the  only  uninfected 
structure  in  a  tuberculous  pulmonary  cavity.  The  arteries  and  veins 
do  not  always  remain  free  from  infection. 

Tuberculosis  from  neighboring  foci  may  extend  into  the  vessel  walls; 
ultimately,  the  intima  and  the  blood  itself  may  be  invaded  by  tubercle 
bacilli.  In  this  manner  generalized  tuberculosis  may  originate.  The 
recovery  of  tubercle  bacilli  from  the  circulating  blood  by  our  present 
technique  has  been  successful  in  very  few  cases.  The  thoracic  duct  is 
sometimes  involved,  not  so  commonly  as  are  the  bloodvessels.  The 
infection  of  the  lymph  in  the  thoracic  duct  usually  takes  place  from  the 
lymph  nodes  of  the  abdomen  or  thorax.  If  such  an  infection  takes  place, 
a  more  or  less  general  tuberculosis  is  inevitable. 

Tuberculosis  occurs  more  frequently  in  the  bronchial  lymph  nodes 
than  in  any  other  organ  or  tissue.  Steiner  and  Neuritter  showed  that, 
in  302  autopsies  in  tuberculous  children,  the  l)ronchial  lymph  nodes 
were  involved  275  times  (91  per  cent.).  In  the  well-known  autop.sy 
reports  of  Northrup,  it  is  noted  that  in  125  autopsies  the  bronchial 
lymph  nodes  showed  tuberculous  changes  in  every  case,  irrespective  of 
the  cause  of  death. 

The  lungs,  pleura,  spleen,  intestines,  liver,  and  meninges  are  involved 
in  the  order  here  named.  In  the  genitourinary  tract  primary  tuber- 
culosis is  relatively  rare.  It  has  been  suggested  that  female  children  are 
more  rarely  attacked  than  women  because  of  the  intact  hymen,  which 
acts  in  obvious  ways  as  a  barrier  to  infection  of  these  parts. 


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TUBERCULOSIS  345 

Miliary  tubercles  are  frequently  found  in  the  genitourinary  tract  as 
a  manifestation  of  generalized  tuberculosis.  Extensive  cheesy  degen- 
eration is  less  common  than  the  miliary  variety;  somewhat  more  frequent 
is  caseous  degeneration  in  the  testicle  and  Fallopian  tubes. 

The  tuberculous  process  produces  indirectly  tissue  changes  as  a  result 
of  the  toxins  produced  by  the  bacilli.  Parenchymatous  degeneration  of 
the  viscera  is  almost  constantly  present.  Areas  of  focal  necrosis  in 
various  organs  not  specifically  tuberculous  are  observed.  The  liver 
shows  more  or  less  fatty  change,  particularly  in  the  pulmonary  cases. 
Amyloid  degeneration  occurs  in  the  protracted  cases  of  tuberculosis. 
The  spleen  and  liver  show"  the  most  striking  changes. 

Etiology.  Heredity.- — Notwithstanding  the  frequency  of  tuberculosis 
during  the  first  period  of  life,  the  existence  of  fetal  and  congenital 
tuberculosis  has,  in  rare  instances,  been  satisfactorily  demonstrated. 
That  infection  may  occur  in  utero  is  well  attested  by  the  case  of  Schmorl 
and  Birch-Hirschfeld.  A  pregnant  woman  died  of  acute  miliary  tuber- 
culosis. In  the  capillaries  of  the  liver  of  the  fetus  as  well  as  in  the 
placenta  tubercle  bacilli  were  found.  Inoculation  with  portions  of  the 
liver  and  kidneys  of  the  fetus  reproduced  the  tuberculosis. 

The  relation  of  paternal  tuberculosis  to  infection  of  the  progeny  has 
been  the  subject  of  much  discussion.  Tubercle  bacilli  may  be  found  in 
spermatozoa.  They  may  occur  in  the  semen  of  men  who  are  suffering 
from  tubercidosis  of  the  genital  apparatus;  on  the  other  hand,  they 
have  also  been  found  in  the  seminal  fluid  of  men  who  were  known  to  be 
tuberculous,  but  whose  genital  organs  were  normal.  Notwithstanding 
these  facts,  and  the  frequency  with  which  these  organs  are  involved 
in  men,  the  transmission  of  tuberculosis  by  male  inoculation  must  be 
considered  unproven.  Experiments  have  shown  that  the  male  may 
present  active  tuberculosis  of  the  genital  organs  at  the  time  of  concep- 
tion, but  the  offspring  may  be  born  free  from  the  disease. 

In  the  ova  of  some  mammals,  as  well  as  in  the  spermatozoa,  tubercle 
bacilli  have  been  found.  Our  knowledge  concerning  the  infection  of 
the  ovum  with  tubercle  bacilli  is,  to  say  the  least,  not  extensive.  Yirchow 
has  pointed  out  that  ova  infected  with  tubercle  bacilli  are  almost 
incapable  of  fecundation.  In  other  words,  he  believes  that  the  activity 
of  the  tubercle  bacillus  would  be  fatal  to  the  cell  life  of  the  egg.  The 
consensus  of  opinion  favors  the  view  that  tuberculosis  is  very  rarely  or 
never  conveyed  to  the  offspring  by  the  ovum. 

In  cases  where  tuberculosis  is  actually  transmitted  from  the  maternal 
organism  to  the  fetus,  we  must  presuppose  the  existence  of  a  tuberculous 
condition  of  the  placenta.  It  is  not  settled  as  a  fact  that  tubercle  bacilli, 
pre-existing  in  the  organism  of  the  mother,  can  pass  from  the  maternal 
to  the  fetal  circulation.  In  a  few  recorded  cases,  where  tuberculosis 
has  occurred  in  the  fetus,  tuberculous  lesions  of  the  placenta  have  been 
demonstrated.  In  the  few  cases  which  have  been  recorded  as  congenital 
tuberculosis,  and  are  considered  authentic,  death  has  occurred  in  utero 
or  in  the  first  few  days  of  extrauterine  life.  There  are  still  those  who 
believe  that  extrauterine  infection  is  not  a  suflficient  cause  to  explain 


340  INFECTIOUS  DISEASES 

the  numerous  cases  of  tuberculosis  that  occur  in  the  first  and  second 
years  of  hfe.  They  beheve  that  the  disease  in  many  chihlren  is  con- 
genital and  remains  latent  until  roused  into  activity  by  some  morbid 
condition  which  lessens  the  resistance  of  the  child.  In  this  way  they 
would  explain  the  sudden  appearance  of  tuberculosis  after  measles 
and  whoopin(f-<'ou>rh.  This  view  of  latent  congenital  tuberculosis  cannot 
be  accepted  in  the  present  state  of  our  knowledge;  indeed,  in  view  of 
the  accumulated  investigations,  the  general  consensus  of  opinion  favors 
the  belief  that  the  large  majority  of  cases  of  tuberculosis  in  children  is 
ac(juire(l,  not  congenital,  in  origin. 

}lodcs  of  Injection. — In  man,  as  in  other  susceptible  animals,  the 
modes  of  infection  are  by  direct  transmission  through  the  excreta,  by 
wounds,  or  bv  the  ingestion  of  food  derived  from  other  infected  animals. 
Tubercle  bacilli  are  sometimes  found  in  the  feces  and  urine  of  patients 
ill  with  intestinal  and  genitourinary  tuberculosis.  In  these  excreta, 
however,  the  bacilli  are  rapidly  rendered  inert  as  a  result  of  the  chemical 
decomposition.  Dried  sputum,  on  the  other  hand,  as  has  been  stated, 
has  been  found  to  contain  virulent  bacilli  four  months  after  expectora- 
tion. The  bacillus  occurs  almost  constantly  in  the  dust  of  rooms  which 
are  occupied  by  tuberculous  patients.  This  is  particularly  true  of  those 
who  cough  and  raise  sputum.  Since  the  bacilli  are  destroyed  by  direct 
sunlight,  they  are  more  likely  to  be  found  in  numbers  in  dark  than  in 
well-lighted  rooms.  It  is  a  matter  of  clinical  as  well  as  of  bacteriological 
knowledge  that  the  absence  of  fresh  air  and  sunlight,  as  well  as  close 
confinement  with  other  individuals  suffering  from  tuberculosis,  forms 
the  most  favorable  condition  for  the  transmission  of  the  disease.  The 
most  common  mode  of  infection  is  the  inhalation  of  dust  containing 
virulent  organisms.  Mouth-to-mouth  infection  was  more  common 
formerly  than  now  ;  midwives  used  to  blow  into  the  mouths  of  the 
newborn  infant  in  order  to  hasten  the  first  respirations. 

The  milk  of  tuberculous  mothers  is  a  source  of  infection.  Tubercle 
bacilli  have  been  found  in  human  milk  in  cases  where  tuberculous 
mastitis  was  present  as  well  as  in  those  cases  where  the  woman  was 
tuberculous,  though  the  breasts  were  not  the  seat  of  disease.  It  is 
believed  by  many  that  the  foregoing  fact  accounts  for  the  relative  fre- 
quency of  intestinal  tuberculosis  in  young  children.  Tubercle  bacilli 
have  also  been  found  in  cows'  milk,  and  there  can  be  no  doubt  that 
in  some  cases  children  are  infected  in  this  manner.  However,  there 
are  many  who  believe  that  the  infection  through  cows'  milk  is  not  as 
frequent  as  was  at  one  time  supposed.  iNIilk  containing  tubercle  bacilli 
would  naturally  produce  primary  intestinal  lesions.  Primary  intes- 
tinal tuberculosis  is  rare  when  compared  with  the  enormous  fre- 
quency of  the  disease  in  cattle,  the  highest  statistics  giving  7.4  per 
cent.  (Heller),  the  lowest  0.5  per  cent.  fCJanghofner)  of  primary  mesen- 
teric or  intestinal  tuberculosis  in  children.  P^nglish  .statistics,  however, 
are  much  higher.  (See  p.  369.)  The  extensive  statistics  of  Ganghofner 
show  no  relation  between  the  occurrence  of  human  tuberculosis  and 
that  of  mammarv  tuberculosis  of  the  cattle  in  the  same  districts.     The 


TUBERCULOSIS  347 

organisms  have  also  been  found  in  many  samples  of  butter  which  have 
proved  virulent  toward  animals.  Meat  of  tuberculous  animals  has  been 
infective  in  isolated  cases.  Since  tuberculosis  of  muscles  is  extremely 
rare,  this  finding  may  have  been  due  to  contamination  with  tuberculous 
material  contained  in  other  parts  of  the  animal's  body. 

Infection  through  wounds  is  relatively  rare  in  children  and  has 
resulted  chiefly  from  vaccination  and  ritual  circumcision.  In  the  latter 
instance  the  source  of  infection  is  usually  the  saliva  of  the  operator, 
who  applies  his  lips  to  the  freshly  made  wound.  This  procedure  for- 
tunately is  rapidly  becoming  obsolete.  The  cervical  lymph  nodes  may 
also  be  infected  through  abrasions  of  the  skin  of  the  face,  as  in  eczema. 

The  bacilli  generally  enter  the  human  body  through  the  respira- 
tory tract.  This  manner  of  invasion  most  satisfactorily  explains  the 
almost  universal  involvement  of  the  bronchial  lymph  nodes  in  young 
tuberculous  subjects.  Many  maintain  that  intestinal  tuberculosis  is 
almost  always  caused  by  the  swallowing  of  sputum  which  is  derived 
from  a  primary  pulmonary  focus.  At  any  rate,  intestinal  or  mesen- 
teric tuberculosis  is  very  rarely  found  to  exist  alone.  Other  organs 
in  remote  parts  of  the  body  are  usually  involved  before  the  intestinal 
or  mesenteric  infection  has  taken  place. 

Predisposing  Factors. — Food  and  general  hygienic  conditions  play 
an  important  role  as  predisposing  factors  to  tuberculosis.  Tuber- 
culosis is  more  common  in  children  of  the  city  than  in  those  of  the 
country.  The  tenement-house  districts  of  a  large  city  are  pre-eminently 
breeding  places  for  tuberculosis.  Many  infants  and  young  children 
are  housed  up  all  winter  in  ill -ventilated,  filthy  rooms.  The  general 
resistance  is  lowered  and  the  invasion  by  the  tubercle  bacillus  is  invited. 
As  has  already  been  stated,  some  of  the  infectious  diseases,  particularly 
measles  and  whooping-cough,  predispose  to  tuberculosis.  These  dis- 
eases nearly  always  cause  enlargement  of  the  cervical  and  bronchial 
lymph  nodes  and  prepare  a  soil  for  tuberculous  invasion. 

Not  every  child  that  inhales  tubercle  bacilli  contracts  the  disease. 
The  production  of  the  disease  depends  partly  on  the  number  of  bacilli 
inhaled;  partly  on  the  susceptibility  of  the  individual.  Any  acute  or 
chronic  disease  of  the  tonsil  facilitates  the  entrance  of  the  bacilli.  The 
tonsils  may  themselves  become  the  seat  of  tuberculous  lesions,  or  the 
bacilli  may  filter  through  the  tissue  of  the  tonsil  into  the  lymphatics  and 
involve  successively  various  groups  of  lymph  nodes  in  the  neck,  thorax, 
and  abdomen,  or  any  other  site  where  lymph  nodes  are  found.  Next  to 
the  lungs,  the  tonsils  are  probably  the  most  common  route  of  entrance. 
Poorly  nourished  children,  as  well  as  those  who  are  of  "lymphatic 
habit,"  with  large  tonsils  and  adenoids  and  generally  enlarged  lymph 
nodes,  are  susceptible  to  infection.  The  habitus  phthisicus — that  con- 
dition which  is  manifested  by  narrow,  flat  chest,  and  drooping  shoulders, 
with  winged  scapulae,  prominent  angulus  Ludovici,  and  weak  inspiratory 
muscles — is  more  frequently  the  result  than  the  cause  of  tuberculosis. 

Injuries  in  some  cases  have  caused  the  sudden  occurrence  of  tuber- 
culous lesions  at  the  site  of  injury.     It  is  obvious  that  a  rapid  tubercu- 


348  INFECTIOUS  DISEASES 

lous  invasion  could  occur  only  in  cases  in  which  tuberculosis  existed 
previously  in  the  body.  Tuberculous  osteomyelitis  and  tuberculous 
meniu<:;itis   may  occur  in   this  way. 

Af/e  of  Occurrence. — As  stated  before,  tuberculosis  is  rarely  found 
in  the  first  weeks  of  life;  with  each  succeeding  year  of  life  the  number 
of  tuberculous  individuals  increases.  In  (590  autopsies  on  childrcMi 
under  one  year  of  age,  Schwer  found  tuberculosis  in  the  following 
number: 

Number  Number  Percent. 

Age                                              of  cases.  tuberculous,  tuberculous. 

One  day  to  one  month 263  0  0 

One  month  to  two  months        ....  123  1  0.8 

Two  months  to  six  months      ....  144  15  10.4 

Six  months  to  twelve  months  ....  160  28  17.5 

In  autopsies  on  children  up  to  fifteen  years  of  age,  Simmonds,  Schwer 
and  Bolz  found  the  following  number  involved  at  various  ages: 

Number  Number  Per  cent. 

Age                                                    of  cases.  tuberculous,  tuberculous. 

Under  one  year 1438  64  4.5 

One  to  five  years 781  230  29.3 

Five  to  ten  years 228  78  35.0 

Ten  to  fifteen  years 162  56  34.6 

Miiller  believes  that  children  from  two  to  four  are  the  most  suscep- 
tible; he  found  this  as  a  result  of  500  autopsies.  The  involvement  by 
years  was  as  follows: 

One  to  five  years 50.7  per  cent. 

Six  to  ten  years 26.0 

Eleven  to  fifteen  years 23.3        " 

Of  those  under  five  years,  over  SO  per  cent,  were  between  two  and 
four;  only  three  cases  were  under  one  year  of  age. 

Diagnosis. — The  diagnosis  of  tuberculosis  in  the  early  period  of 
infection  is  beset  with  difficulties.  The  onset  of  the  disease  may  be 
insidious  and  its  progress  slow.  The  production  of  gross  tissue  changes 
may  be  protracted.  While  it  is  true  that  the  bacilli  may  have  gained 
access  to  the  organism  and  may  be  active  in  the  production  of  to.xins, 
it  will  be  noted  later  that  we  have  not  as  yet  any  satisfactory  method 
of  recognizing  toxic  substances  of  tuberculous  origin.  The  family 
history  should  be  inquired  into,  not  only  on  account  of  the  hereditary 
influence,  but  also  because  the  presence  of  tuberculosis  in  the  family 
suggests  the  possibility  of  a  house  or  contact  infection.  More  impor- 
tant than  the  family  history  is  the  information  derived  from  the  environ- 
ment of  the  patient,  particularly  as  to  whether  or  not  there  has  been 
any  direct  exposure  to  infection.  Local  tuberculous  tLssue  changes 
appear  somewhat  later  in  the  disea.se;  .so  that,  as  a  matter  of  fact,  what 
we  ordinarily  consider  as  incipient  tuberculosis  in  a  clinical  way  con- 
sists in  every  instance  of  more  or  less  actually  established  tuberculous 
infiltration. 

Of  the  various  diagnostic  resources,  the  information  derived  from 
finding  the  tubercle  bacilli  in  excreta,  exudates,  or  tissues  is  the  most 
positive.     In  the  pulmonary  cases  bacilli  are  not  usually  found  in  the 


TUBERCULOSIS  349 

sputum  until  more  or  less  extensive  destruction  of  tissue  has  occurred. 
Even  in  the  cases  where  the  sputum  is  abundant  it  is  not  obtainable 
because  infants  and  children  very  seldom  expectorate.  (To  obtain 
sputum  from  young  children  for  examination  the  index  finger  is  covered 
with  a  strip  of  gauze  and  introduced  well  into  the  pharynx,  so  as  to 
irritate  the  epiglottis;  the  coughing  which  occurs  as  a  result  of  the  irri- 
tation will  frequently  cause  the  expectoration  of  sputum;  this  may  be 
caught  up  on  the  gauze  sponge,  diluted  in  a  small  quantity  of  sterile 
water,  and  examined  for  tubercle  bacilli.)  The  examination  of  other 
excreta  or  exudates  for  tubercle  bacilli  should  be  made  in  appropriate 
cases,  though  the  results  are  not  always  satisfactory.  The  examination 
of  tuberculous  exudates,  such  as  cerebrospinal,  pleuritic,  ascitic,  and 
other  fluids,  which  always  contain  very  few  bacilli,  is  most  effectually 
made  by  inoculating  the  fluids  into  animals,  and  at  least  10  or  15  cm.  of 
the  exudate  should  be  used.  Guinea-pigs  and  rabbits  are  most  suitable 
for  this  purpose.  The  animal  may  fall  sick  and  die  from  the  disease  in 
two  or  three  weeks,  though  several  months  may  elapse  before  a  decisive 
reaction  occurs. 

Cytodiagnosis,  which  attempts  to  distinguish  the  nature  of  the  exudate 
by  the  character  of  the  contained  cells,  is  not  altogether  reliable.  While 
it  is  true  that  in  most  tuberculous  exudates  lymphocytes  are  the  pre- 
dominating elements,  non-tuberculous  exudates  may  show  the  same 
condition.  The  examination  of  exudates  is  obviously  of  only  limited 
application.  It  is  evident  that  tuberculosis  of  the  solid  viscera,  lymph 
nodes,  etc.,  is  not  within  the  range  of  this  latter  method  of  diagnosis. 

The  serum  diagnosis  of  tuberculosis  devised  by  Arloing  and  Cour- 
mont  has  proved  of  relatively  little  value.  The  technique  employed 
is  similar  to  that  of  the  Widal  examination  for  typhoid  fever.  The 
homogeneous  bouillon  culture  of  tubercle  bacilli  is  used  for  the  test. 
To  this  bouillon  culture  may  be  added  suspected  blood  serum,  or  any 
of  the  body  fluids.  If  the  test  is  positive  in  a  1 :  20  solution,  agglutina- 
tion of  the  bacilli  will  occur  in  about  twelve  to  fifteen  hours.  Solutions 
in  a  strength  of  1 :  5  to  1 :  50  should  be  employed  for  the  same  test;  ordi- 
narily the  reaction  occurs  in  from  two  to  six  hours.  It  is  believed  that 
the  tubercle  bacillus  is  not  motile;  consequently,  the  test  for  motility 
cannot  be  applied  as  in  the  Widal  test.  In  adults  the  test  is  of  little 
value,  since  many  have  latent  tuberculosis.  The  test  may  prove  of 
greater  value  in  children,  because  latent  tuberculosis  is  relatively  less 
frequent.  Agglutination  has  been  found  when  no  tuberculosis  was 
present.  On  the  other  hand,  tuberculosis  has  been  present  and  the 
reaction  has  proved  negative.  In  miliary  tuberculosis  particularly, 
the  serum  reaction  has  proved  of  little  value  in  diagnosis. 

Of  the  various  methods  for  the  diagnosis  of  occult  tuberculosis,  the 
most  valuable  one  at  present  is  the  injection  of  tuberculin.  Tuber- 
culin should  not  be  injected  in  patients  who  are  having  fever.  If  the 
tuberculous  patient  is  running  a  febrile  course,  the  injection  of  tuber- 
culin is  likely  to  cause  destructive  changes  in  the  actively  inflamed 
tuberculous  tissues.    Again,  if  the  patient  is  febrile  before  the  injection, 


350  INFECTIOUS  DISEASES 

it  is  difficult  or  impossible  to  know  whether  the  rise  in  temperature  is 
due  to  the  tuberculin  or  simply  a  fluctuation  in  the  temperature  due 
to  the  disease.  It  is  not  to  be  denied  that  the  use  of  tuberculin  has 
been  harmful  to  some  patients.  It  is  possible  to  change  a  latent  focus 
into  an  active  one.  The  most  experienced  and  careful  clinicians,  how- 
ever, resort  to  the  use  of  this  injection,  and  believe  that  no  harm  results 
if  small  doses  are  employed.  Artificial  sera,  such  as  physiological  salt 
solution,  have  been  injected  in  place  of  tuberculin.  They  give  reac- 
tions in  most  cases,  producing  rise  of  temperature  and  chill,  probably 
acting  in  a  similar  way  on  the  tuberculous  tissue  as  the  tuberculin. 
They  are  not,  however,  so  reliable  as  tuberculin,  and  are  probably  just 
as  harmful. 

Koch  has  prepared  two  varieties  of  tuberculin,  one  of  which  is  advo- 
cated for  diagnostic  and  the  other  more  especially  for  therapeutic 
use.  The  first  one  is  obtained  from  a  culture  of  the  bacilli  in  alkaline 
glycerin-bouillon.  Of  this  preparation  1  mg.  introduced  hypodermically 
into  non-tuberculous  individuals  produces  no  effect;  in  the  tuberculous 
the  temperature  rises  to  39°  to  41°  C.  (102°  to  105°  F.),  usually  pre- 
ceded by  a  chill,  and  often  with  pains  in  the  limbs,  nausea,  and  vomit- 
ing, occasionally  with  cerebral  symptoms;  at  the  same  time  the  local 
findings  become  marked.  In  one  to  four  days  the  reaction  disappears 
and  can  be  made  to  reappear  only  with  larger  doses.  Recent  observers 
have  advised  beginning  with  smaller  doses,  y^,y  mgm.,  and  increasing  to 
1  mgm.  in  cases  where  the  reaction  is  not  sufficiently  marked.  If  con- 
ducted in  this  way  the  procedure  is  less  dangerous  to  the  patient. 

The  second  tuberculin,  which  Koch  now  advocates,  especially  for 
purposes  of  immunization,  is  obtained  from  a  culture  of  tubercle  bacilli 
thoroughly  dried,  ground  up  in  a  mortar,  and  shaken  up  well  in  dis- 
tilled water.  The  mixture  is  then  centrifugalized  and  the  supernatant 
fhiid  is  preserved  for  use  by  the  addition  of  20  parts  of  glycerin  in  100. 
For  therapeutic  use  5^  mgm.  may  be  injected,  and  is  increased  grad- 
ually to  1  mg.,  when  the  first  marked  improvement  is  said  to  occur. 
It  is  not  desirable  that  a  reaction  of  more  than  1°  C.  (1.8°  F.)  occur  as 
a  result  of  these  injections. 


TUBERCULOUS  DIATHESIS. 

This  condition  is  frequently  described  as  "scrofula."  This  is  an  old 
term  and  has  a  mixed  meaning.  Proj)erly  applied,  the  term  refers  to 
inherited  or  congenital  weakness,  or  lack  of  resistance,  which  is  mani- 
fested by  enlargement  of  the  lymph  nodes,  particularly  in  the  cervical 
region;  also  by  anemia  and  frequently  by  eczema  of  the  face  and  eyelids. 
Cornet  has  concluded  not  to  abandon  the  term  scrofula  because  he 
believes  that  scrofula  includes  a  larger  class  of  disorders  than  those 
which  are  tuberculous.  He  considers  tiiree  forms  of  scrofula:  first, 
tuberculous;  second,  the  non-tuberculous  or  pyogenic;  third,  the 
mixed  forms — a  combination  of  the  first  two.     It  is  true  that  in  many 


TUBERCULOSIS  351 

so-called  cases  of  scrofulous  lymph  nodes,  tubercle  bacilli  may  be 
fouiul,  or  tuberculosis  may  be  produced  in  animals  by  inoculation 
with  parts  of  the  infected  nodes.  On  the  other  hand,  in  some  of  the 
cases  the  lymph  nodes  are  enlarged  as  a  result  of  other  infections. 
Probably  streptococci  and  staphylococci  of  slight  virulence  may  cause 
lymphadenitis.  These  organisms  may  gain  access  to  the  lymph  nodes 
through  diseased  tonsils  and  lesions  of  the  face. 

Laser  found  among  1216  school  children  only  137  (11.3  per  cent.) 
free  from  enlargement  of  lymph  nodes.  In  the  majority  of  the  cases  the 
enlargement  occurred  after  acute  infectious  diseases,  as  whooping- 
cough  and  measles  or  from  adenoids.  In  the  minority  of  the  cases  the 
nodes  were  tuberculous.  A  chronic  lymphatic  enlargement  may  be 
brought  about  by  inflammation  of  skin  and  mucous  membranes  (eczema, 
catarrh  of  nose  and  throat,  blepharitis,  hypertrophy  of  the  tonsils, 
ulceration  of  the  gums).  A  very  important  factor  in  the  etiology  of 
enlarged  lymph  nodes  is  caries  of  the  teeth. 


TUBERCULOSIS  OF  THE  LYMPH  NODES. 

Tuberculosis  of  the  lymph  nodes  occurs  in  two  forms:  first,  the 
localized  form  which  usually  affects  single  nodes  or  groups  of  nodes, 
and,  second,  the  generalized,  in  which  all  of  the  lymph  nodes  in  the 
body  may  become  tuberculous.  In  the  first  group  the  nodes  most 
often  involved  are  the  bronchial,  mesenteric,  mediastinal,  and  cervical. 
In  a  report  of  500  autopsies  on  children  in  whom  tuberculous  lymph- 
adenitis existed,  the  various  nodes  were  attacked  in  the  order  men- 
tioned (Miiller): 

Bronchial 81.7  per  cent. 

Mesenteric 57.1  " 

Mediastinal 11.1  " 

Cervical 8.8  " 

Retroperitoneal 7.1  " 

Portal 4.8 

Epigastric 3.2 

Ketromaxillary 2.4  " 

Inguinal 2.4  " 

The  cervical  lymph  nodes  are  most  frequently  infected  from  abra- 
sions on  the  tonsils,  in  the  mouth,  or  on  the  face.  The  bronchial  nodes 
are  usually  infected  through  the  lungs ;  sometimes  the  infection  spreads 
through  the  lymphatics  from  the  cervical  nodes.  The  mesenteric 
.nodes  are  usually  infected  through  the  intestinal  tract.  The  primary 
lesion,  through  which  the  infection  gains  access  to  the  lymph  nodes, 
may  be  insignificant  in  size.  The  loss  of  epithelium  or  a  slight  wound 
is  sufficient  to  permit  the  passage  of  tubercle  bacilli.  The  point  through 
which  the  bacilli  enter  need  not  be  tuberculous  in  character.  The 
most  careful  postmortem  examination  may  fail  to  trace  the  path  which 
the  infection  took.  This  failure  to  find  the  route  of  infection  led  to 
the  belief  that  the  involvement  of  the  lymph  node  was  frequently  hema- 


352  INFECTIOUS  DISEASES 

togenous.  It  has  also  been  claimed  that  tubercle  bacilli  may  pass 
through  intact  nuicous  membrane,  though  recent  investigators  have 
shown  conclusively  that  this  theory  is  untenable.  Any  non-tubercu- 
lous inflammatory  condition  of  the  mucous  membranes  increases  the 
susceptibility  of  these  structures  as  well  as  of  the  underlying  lymph 
node  to  tuberculous  infection.  In  that  class  of  cases  where  a  single 
group  of  nodes  becomes  tuberculous  they  usually  grow  to  a  large  size 
and  caseate.  In  all  such  cases  inflammation  occurs  in  the  capsule  of 
the  node  and  the  surrounding  tissue;  this  is  spoken  of  as  periadenitis.  In 
consequence  of  this  inflammation  around  the  node  the  latter  becomes 
adherent  to  the  surrounding  tissue  as  well  as  to  the  other  nodes.  Some- 
times a  process  of  repair  occurs;  then  the  necrotic  tissue  is  surrounded 
by  a  thick,  fibrous  capsule,  which,  in  the  course  of  time  may  become 
infiltrated  with  lime-salts.  As  is  well  known,  nature  adopts  this  method 
frecjuently  in  curing  tuberculous  foci.  In  other  cases  the  centre  be- 
comes litjuid,  the  skin  becomes  adherent  to  the  inflammatory  mass 
and  the  abscess  ruptures  externally.  Upon  microscopic  examination 
the  tissues  of  the  lymph  nodes  present  the  same  appearance  as  tuber- 
culosis in  other  tissues.  At  best,  only  a  few  tubercle  bacilli  are  found 
in  the  infected  nodes. 

In  that  variety  which  I  have  spoken  of  as  generalized  tuberculous 
Ivmphadenitis,  numerous  groups  or  all  of  the  lymph  nodes  of  the  body 
are  involved.  In  this  variety  the  process  usually  begins  in  the  neck 
or  thorax  and  progresses  by  way  of  the  lymphatics  to  the  axillary,  medi- 
astinal, retroperitoneal,  mesenteric,  and  inguinal  lymph  nodes.  If 
these  are  examined,  tubercles  may  be  identified  microscopically  and 
macroscopically. 

In  this  connection  another  variety  of  tuberculosis  of  the  lymph  nodes 
should  be  mentioned.  Some  of  the  cases  which  were  formerly  described 
as  Hodgkin's  disease  are  a  form  of  generalized  iuhercuknis  lymphade- 
nitis, which  differs  from  the  varieties  previously  described  and  stands 
out  by  itself  as  a  distinct  type,  which  the  work  of  Reed  and  also  of 
Longcope  would  tend  to  show.  These  nodes  may  be  separate,  or  they 
may  form  adherent  masses  with  one  another.  Tliey  vary  greatly  as  to 
their  consistency,  some  being  cpiite  firm,  others  being  almost  gelatinous. 
Upon  macroscopic  examination  they  do  not  show^  any  necrotic  areas. 
The  individual  nodes  vary  in  size  from  a  bean  to  a  walnut,  and  the 
coalesced  masses  may  be  as  large  as  an  orange.  Upon  microscopic 
examination  these  nodes  are  sometimes  found  to  contain  many  small, 
typical  tubercles  surrounded  by  areas  of  lymphatic  hyperplasia.  The 
lymphatic  tissue  cannot  be  differentiated  from  the  normal  variety. 
In  most  of  the  cases  of  this  class,  tubercles  are  entirely  absent.  The 
connective  tissue  is  greatly  increased  and  it  is  to  be  especially  noticed 
that  small  areas  of  necrosis  are  found.  In  these  necrotic  areas  large, 
pale  cells  appear  with  a  variable  number  of  nuclei  from  1  to  5  or  6. 
These  peculiar  cells  are  not  identical  with  epithelioid  cells,  and  are 
believed  to  be  characteristic  of  tuberculosis  (Sternberg).  Sometimes 
true  ffiant  cells  are  found.     It  is  extremely  difficult  to  find  tubercle 


TUBERCULOSIS  353 

bacilli  in  this  variety  of  tuberculosis  of  the  lymph  nodes,  and  the  real 
nature  of  the  disease  often  remains  entirely  unknown,  or  until  pieces 
of  tissue  have  been  injected  into  animals.  This  variety  of  tuberculous 
adenitis  does  not  caseate.  ^Macroscopic  areas  of  necrosis  remain  absent 
as  a  rule,  notwishstanding  their  progressive  enlargement  for  years. 
The  similarity  between  this  type  of  tuberculosis  of  the  lymph  nodes 
and  that  which  occurs  in  cattle  has  recently  led  some  writers  to  express 
the  belief  that  bovine  tubercle  bacilli  were  the  infective  agents  in  these 
nodes.  The  belief  is  general,  though  not  unanimous  at  the  present 
time,  that  the  tubercle  bacilli  of  men  and  cattle  are  of  the  same  species. 

Symptomatology. — Tuberculosis  of  the  lymph  nodes,  as  a  rule,  has  no 
decided  influence  on  the  general  health.  In  a  small  number  of  cases 
constitutional  disturbances  are  present.  Sometimes  the  patients  be- 
come anemic,  lose  in  weight,  and  complain  of  loss  of  appetite.  Fever  is 
not  the  rule  in  uncomplicated  cases;  in  the  pseudoleukemic  cases  the 
temperature  may  reach  40°  C.  (104°  F.).  If  fever  occurs  in  the  other  cases 
it  is  usually  due  to  a  mixed  infection  with  pus  organisms  or  the  existence 
of  a  tuberculous  process  in  other  organs,  most  commonly  the  lungs. 
As  a  general  rule,  the  nodes  are  painless.  In  those  rare  cases  where 
pain  does  occur,  it  may  be  explained  by  the  acute  inflammatory  changes 
within  the  nodes;  or  it  may  be  the  result  of  compression  or  the  enclo- 
sure of  nerves  within  the  inflammatory  mass;  thence  the  neuralgias 
which  occur  in  cervical  adenitis.  Exceptionally,  neighboring  organs, 
like  the  esophagus  or  trachea,  may  be  pressed  upon;  26  to  28  per  cent, 
of  patients  sufl^ering  from  adenitis  have  at  the  same  time  pulmonary 
tuberculosis;  from  the  latter  disease  many  die.  Less  frequent,  though 
by  no  means  rare,  are  combinations  of  tuberculous  adenitis  with  tuber- 
culous affections  of  the  bones  and  joints. 

jMixed  infection  with  pyogenic  organisms  occurs  relatively  frequently; 
this  causes  acute  suppuration  of  the  node  and  an  abscess  around  it. 
The  nature  of  such  an  abscess  is  frequently  determined  at  the  opei'a- 
tion,  when  it  is  found  that  the  abscess  contains,  in  addition  to  the  pus, 
caseous  material.  The  suppurative  process  may  eliminate  the  tuber- 
culous tissue,  and  in  this  way  nature  brings  about  a  spontaneous  cure. 
Recovery  from  tuberculous  lymph  nodes  may  occur  in  every  stage  of 
the  disease;  in  hyperplastic  lymph  nodes  connective-tissue  proliferation 
may  cause  scar  tissue  and  recovery.  Encapsulation  by  connective  tissue 
or  calcium  salts  are  methods  of  cure,  which  have  already  been  referred  to. 

Cervical  Lymph  Nodes. — The  clinical  course  is  manifold;  at  one 
time  one  has  to  do  with  a  medium-sized  movable  tumor  in  the  sub- 
maxillary region;  at  another  time  fistulse  and  ulcers  over  both  sides 
of  the  neck  cover  large  masses  of  lymph  nodes.  A  solitary  lymph  node 
may  be  involved,  or  the  nodes  which  constitute  a  group  may  coalesce 
to  form  a  large  tumor  mass,  or  the  infection  may  extend  from  one  group 
to  a  neighboring  group  until  several  are  involved.  Sometimes  these 
various  collections  m.ay  coalesce  to  form  a  large  tumor  mass.  This 
affection  is  often  bilateral  (Fig.  70), 

Sometimes  the  capsule  of  the  nodes  is  involved  in  the  inflammation 
23 


354 


INFECTIOUS  DISEASES 


going  on  within.  This  leads  to  thickening  as  well  as  adhesion  to  the 
neiglil)()ring  organs.  On  aeconnt  of  the  eoinieetive-tissne  growth  the 
noiles  become  fixed  and  immovable.  The  mass  becomes  adherent 
to  the  skin.  The  skin  becomes  edematous,  tense,  and  discolored;  the 
affected  area  prominent  and  gradually  thins  out;  eventually  it  per- 
forates and  the  abscess  empties  itself;  a  fistula  remnins.  which  leads 
into  the  abscess  cavity.     If  the  process    continues   for  a  longer  time 

Fig.  70 


Tuberculosis  of  cervical  and  axillary  lymph  nodes  in  an  eight-year-old  boy. 

ulcerations  of  the  skin  persist  and  granulations  appear  at  the  opening. 
In  other  cases,  where  the  nodes  lie  more  deeply,  the  abscess  may  pass 
between  the  layers  of  the  fascia  or  along  the  sheaths  of  the  great  vessels 
and  perforate  the  skin  at  some  distance — over  the  clavicle  or  at  the 
sternal  notch,  even  over  the  anterior  surface  of  the  thorax.  In  these 
cases  persistent  fistulous  tracts  remain. 

Bronchial  Lymph  Nodes. — The  bronchial   nodes   may  be  enlarged 
without  causing  pressure  symptoms;  on  the  other  hand,  serious  dis- 


TUBERCULOSIS  355 

turbances  may  be  produced.  Pressure  on  the  trachea  and  bronchi 
causes  narrowing  of  the  air  passages,  resulting  in  dyspnea.  Cough  is 
an  early  symptom  of  pressure.  It  is  frequently  paroxysmal  in  char- 
acter and  may  resemble  the  cough  of  pertussis,  except  that  there  is 
no  crowing  inspiration.  The  paroxysms  may  be  violent  and  exhaust- 
ing, ending  in  vomiting.  As  the  result  of  the  pressure  of  the  mass  of 
nodes,  secondary  tracheitis,  or  tracheobronchitis,  may  be  produced. 
If  this  occurs,  the  lumen  of  the  bronchi  is  narrowed  still  more.  The 
attack  of  coughing  is  at  times  more  frequent  at  night;  the  dyspnea  is 
of  an  asthmatic  type,  greater  on  expiration  than  on  inspiration ;  the  sleep 
is  in  consequence  often  restless;  dyspnea  on  even  slight  exertion  occurs. 
In  some  cases  sudden  death  has  occurred  where  enlarged  bronchial 
lymph  nodes  had  not  been  suspected.  Upon  autopsy  it  has  been  shown 
that  a  mass  of  bronchial  nodes  narrowed  the  lumen  of  the  bronchi, 
and  in  most  cases  complete  closure  occurred  as  a  result  of  a  bronchitis 
secondary  to  whooping-cough  or  measles.  In  other  cases,  where  a 
node  has  undergone  caseous  degeneration,  the  mass  has  ruptured 
into  the  bronchi,  and  relief  has  been  obtained  from  the  pressure  symp- 
toms, though  very  soon  an  acute  miliary  tuberculosis  of  the  pulmonary 
type  has  appeared.  The  recurrent  laryngeal  or  pneumogastric  nerves 
may  be  pressed  upon  or  may  be  involved  in  adhesions  in  the  peri- 
nodular  connective  tissue.  In  these  cases  the  symptoms  are  referred 
to  the  larynx  or  stomach.  The  cough  is  hacking  and  hoarse  without 
expectoration;  the  voice  becomes  harsh  on  account  of  the  paralysis 
of  the  vocal  cords,  or  aphonia  may  occur.  Compression  of  the  esoph- 
agus, lungs,  or  other  viscera  sometimes  occurs,  but  symptoms  from  this 
source  are  rare.  There  may  be  pressure  on  the  superior  vena  cava, 
in  which  case  cyanosis  and  edema  of  the  head  and  upper  extremities 
with  enlargement  of  the  superficial  veins  of  the  thorax  would  be  the 
most  prominent  symptoms.  Fronz  reported  two  very  unusual  cases, 
in  which  the  large  mass  of  tuberculous  bronchial  node  tissue  escaped 
from  its  capsule  and  ruptured  into  a  bronchus.  Once  in  a  bronchus, 
it  acted  as  a  foreign  body.  The  patient  in  attempting  to  dislodge  this 
tissue  from  the  bronchus  succeeded  in  forcing  it  into  the  larynx,  where 
it  caused  death  by  asphyxia. 

Physical  signs  of  tuberculous  bronchial  nodes  are  not  always  dis- 
covered by  our  methods  of  physical  examination.  When  it  is  found 
that  the  supraclavicular  nodes  are  larger  than  the  cervical  nodes,  and 
no  other  cause  for  their  enlargement  is  found,  it  may  be  assumed  that 
the  bronchial  lymph  nodes  are  likewise  affected.  There  is  a  direct 
connection  between  the  tracheobronchial  nodes  and  the  cervical  ones. 
From  this  we  would  expect  both  to  be  involved  from  one  infection. 
Hoffmann  has  observed  that  in  cases  of  tuberculous  bronchial  nodes 
enlarged  lymph  nodes  may  often  be  felt  at  the  sternal  notch,  if  the  head 
be  bent  forward.  If  the  lymph  nodes  are  sufficiently  large,  dulness 
may  be  elicited  by  percussing  over  the  sternum,  particularly  over  the 
manubrium.  If  this  dulness  extends  laterally  on  either  side  of  the  hone, 
it  is  a  sign  of  some  value,     Dulness  over  the  sternum  may  be  found 


350 


INFECTIOUS  DISEASES 


Fig. 71 


also  ill  enlarged  thyinus,  th()ii<2;h  in  this  case  the  dnlness  does  not  extend, 
as  a  rule,  beyond  the  lateral  margins  of  the  bone.  The  lungs  cover 
these  nodes  in  front,  and  a  resonant  percussion  note  may  be  obtained 
even  if  the  nodes  are  considerably  involved.  It  has  been  suggested  that 
interscapular  dulness  was  of  diagnostic  value,  but  the  amount  of  over- 
Iving  lung  tissue  is  greater  here  than  in  front,  so  that  dulness  is  rarely 
obtained  in  the  interscapular  region.  But,  as  Hall  points  out,  more 
depends  upon  tlie  size  of  the  diseased  nodes  than  upon  all  other  factors. 
If  there  be  considerable  pressure  over  one  bronchus,  a  difference  in 
the  breath  sounds  of  the  two  sides  may  result.  .  Owing  to  the  anatom- 
ical position  of  the  right  bronchus, 
rousrhened  breathing  of  this  side  must 
be  interpreted  cautiously;  nevertheless, 
any  great  difference  in  the  breathing 
between  the  two  sides  should  be  carefully 
noted.  Bronchovesicular  breathing  on 
the  left  side,  with  prolonged  and  harsh 
respiration,  is  always  suggestive.  Plx- 
treme  compression  of  one  of  the  primary 
bronchi  may  cause  a  diminution  of  the 
breath  sounds.  Rilliet  and  Barthez 
believe  that  enlarged  bronchial  lymph 
nodes  may  at  times  conduct  the  tubu- 
lar breathing  to  the  surface,  even  though 
there  be  no  consolidation  of  the  interven- 
ing lung.  A  venous  hum  is  sometimes 
heard  over  the  manubrium.  Eustace 
Smith  pointed  out  that  if  a  child  is  in  a 
recumbent  position  with  head  thrown 
buck,  a  venous  murmur  occurs  and  dis- 
appears again  when  the  head  is  flexed. 
It  is  believed  that  by  extending  the 
head  on  the  neck  the  nodes  are  brought 
close  to  the  sternum  and  in  this  manner 
cause  compression  of  the  left  innomi- 
nate vein.  Smith  believed  that  this  sign 
was  diagnostic  of  enlarged  bronchial 
Ivmph  nodes.  He  thought  that  a  per- 
sistently enlarged  thymus  or  any  other 
tumor  would  not  be  likely  to  cause  this 
symptom  (Fig.  71).  More  recent  observations  have  shown,  however, 
that  this  venous  hum  is  sometimes  heard  in  children  without  any  disease 
whatever  in  the  bronchial  nodes.  Petruschky  has  pointed  out  that 
these  patients  frc((uently  suffer  from  spinalgia;  he  considers  this  a  fre- 
quent and  important  phenomenon.  He  believes  this  sign  is  present  in 
about  90  per  cent,  of  all  cases.  Some  of  the  vertebr.T  are  more  dis- 
tinctly tender  than  others.  The  vertebra  involved  naturally  depend 
upon  the  location  of  the  tuberculous  nodes. 


Disseminated   tuberculosis  of  the  lympii 
nodes  in  a  fourteen-year-old  boy. 


TUBERCULOSIS  357 

Generalized  Tuherculous  Lijmphadenitis. — This  form  of  aiberculous 
lymphadenitis  presents  many  of  the  same  symptoms  as  Hodgkin's 
disease,  with  which  it  was  confounded  until  recently.  There  is  usually 
more  or  less  wasting  with  anemia  of  a  secondary  type.  Leukopenia 
is  more  frecjuent  than  an  increase  of  the  leukocytes.  Fever  occurs  as 
a  rule,  which  varies  greatly  in  its  course.  The  chronic  intermittent 
fever,  which  Ebstein  described  as  being  associated  with  pseudoleuke- 
mia, is  also  found  with  generalized  tuberculous  lymphadenitis.  This 
symptom  is  characterized  by  periods  of  remittent  fever,  lasting  seven 
to  ten  days,  alternating  with  periods  of  apyrexia  of  like  duration. 

The  striking  features  of  the  clinical  picture  are  the  large  masses  of 
lymph  nodes  which  appear  in  the  course  of  the  first  few  months.  The 
cervical  nodes  are  first  in  evidence,  later  the  axillary,  and  finallv  the 
inguinal.  Later  on  the  nodes  in  the  thorax  and  abdomen  also  enlarge, 
the  infection  progressing  rapidly  downward  from  the  neck  and  involv- 
ing successively  the  mediastinal,  bronchial,  retroperitoneal,  and  iliac 
lymph  nodes.  The  last  are  often  palpated  as  large  intra-abdominal 
tumors.  The  nodes  are  usuallv  firm  and  freely  movable;  they  do  not 
coalesce  with  neighboring  nodes.  At  times  they  are  soft.  They  may 
become  firmlv  fixed.  In  some  cases  thev  necrose  and  break  throucjh 
the  overlying  skin.  The  growth  is  usually  continuous;  there  may, 
however,  be  short  periods  during  which  these  nodes  remain  stationary. 
Or,  as  a  result  of  local  medication  they  may  diminish  slightly  in  size. 
(The  cases  terminate  fatally,  usually  as  a  result  of  some  intercurrent 
acute  infection.)  Other  symptoms  depend  on  pressure  of  the  enlarged 
nodes  on  neighboring  structures,  and  also  on  the  increasing  cachexia. 

Diagnosis. — The  diagnosis  of  superficial  tuberculous  nodes  is  com- 
paratively simple.  The  most  important  points  are  the  persistence, 
after  the  presumable  cause  of  their  enlargement  has  disappeared, 
absence  of  pain  and  tenderness,  and  the  tendency  to  form  abscesses 
with  fistidte  which  heal  slowly.  A  history  of  tuberculosis  in  the  family 
and  its  presence  in  other  parts  of  the  body  are  also  of  value  in  the 
diagnosis.  Actinomycotic  processes  are  differentiated  by  the  discovery 
of  ray  fungi  in  the  pus;  syphilis,  by  the  presence  of  other  specific  lesions 
and  the  results  of  antisyphilitic  treatment.  Nodes  enlarged  as  the 
result  of  a  mild  pyogenic  infection  must  also  be  distinguished  from 
tuberculous  lymph  nodes.  AMien  all  other  measures  fail,  a  node  may 
be  excised  and  the  diagnosis  established  bv  histological  examination 
or  inoculation  into  animals. 

The  diagnosis  of  the  condition  within  the  interior  of  the  nodes  is  often 
difficult  or  impossible.  Sometimes  the  consistence  of  the  nodes  is  so  soft 
that  fluctuation  is  suspected;  at  other  times  an  abscess  in  the  centre  of 
a  node  is  not  suspected,  on  account  of  the  relative  thickness  of  the 
surrounding;  scar  tissue;  the  extent  of  the  disease,  too,  cannot  alwavs 
be  determined.  The  surgeon  is  fi'equently  surprised  to  find  that  the 
enlarged  nodes  are  more  numerous  and  extend  more  deeply  than  super- 
ficial examination  gave  reason  to  suppose. 

The  diagnosis  of  tuberculous  bronchial  nodes  presents  great  diffi- 


358  INFECTIOUS  DISEASES 

culty  at  times.  Early  in  the  course  of  the  affection  the  diagnosis  is 
often  inipi)ssil)le.  Tlie  most  important  symptoms  upon  whieli  (Ha<)'nosis 
may  he  hased  are  pressure  symptoms — especially  the  asthmatic  type  of 
inspiration.  The  signs  of  Eustace  Smith  and  Petruschky  offer  at  least 
corroborative  evidence.  An  absolute  and  relative  lymphocytosis,  as 
suggested  by  Friedliinder,  may  prove  of  some  value.  Dulness  over 
the  superior  part  of  the  sternum  or  in  the  intrascapnlar  region,  with 
a  hoarse  cough  or  aphonia,  pressure  symptoms  on  the  vagus,  the  blood- 
vessels, esophagus,  tracheobronchi,  and  lungs,  are  of  great  impor- 
tance, but  are  found  only  in  the  latter  stages  of  the  disease. 

The  diagnosis  of  tuberculous  nodes  in  the  mesentery  or  retroperi- 
toneum  depends  chiefiy  on  the  j^ressure  symptoms  which  are  produced. 
Sometimes  they  can  be  elicited  by  abdominal  examination  or  by  biman- 
ual examination  per  rectum. 

General  tuberculous  lymphadenitis  must  be  distinguished  from 
leukemia,  lym])hosarcoma,  pseudoleukemia,  and  syphilis.  Leukemia 
is  easily  excluded  by  an  examination  of  the  blood.  I>ymphosarcoma 
usually  begins  in  the  mediastinal  or  retroperitoneal  nodes.  These 
nodes  have  already  grown  to  considerable  size  before  the  lymph  nodes 
in  other  regions  are  in  evidence.  In  physical  examination  of  tliese 
cases,  during  the  first  stage  of  the  disease,  dulness  may  be  elicited 
over  the  sternum  and  under  the  clavicles  for  a  considei-ablc  distance. 
This  is  due  to  the  fact  that  the  lyjnphosarcoma  tends  to  infiltrate  the 
tissue  surrounding  the  nodes,  particularly  the  lungs  and  the  pleura. 
This  may  be  observed  when  the  nodes  in  the  neck  and  groin  are  still 
insignificant  in  size.  The  differentiation  of  tuberculous  lymphadenitis 
from  pseudoleukemia  can  be  made  only  by  microscopic  examination 
of  the  nodes,  though  the  presence  of  fever  and  tuberculous  lesions  in 
other  parts  of  the  body  speak  in  favor  of  the  diagnosis  of  tubercu- 
losis.    The  tuberculin  test  may  be  needed. 

Prognosis. — The  prognosis  is  always  serious.  It  depends  upon  the 
form  of  the  lymph-node  tuberculosis,  the  age,  and  the  constitution  of 
the  patient.  The  principal  danger  is  of  the  disease  becoming  general. 
This  may  occur  in  the  following  ways:  ].  P>xtension  of  the  disease 
along  the  lymphatic  system  (pseudoleukemic  form).  2.  Extension 
through  the  vascular  system,  as  where  a  caseous  node  breaks  into  tlie 
jugular  vein — sometimes  no  cause  for  the  vascular  distribution  can 
be  determined.  General  acute  tuberculosis  is  sometimes  observed 
after  operations,  particularly  where  large  vessels  have  been  opened. 
3.  A  pulmonary  tuberculosis  may  develop,  which  leads  rapidly  to 
death.  4.  The  development  of  tuberculosis  in  other  organs,  bones, 
joints,  and  meninges. 

In  general,  tuberculosis  of  the  cervical  lymph  nodes  is  the  form  of 
the  disease  that  remains  localized  for  the  longest  time.  Whether  the 
cases  will  remain  local  or  become  general  caiuiot  be  foretold;  there  are 
benign  and  malignant  cases.  In  the  chronic  cases  amyloid  degeneration 
leading  to  death  may  occur.  Spontaneous  cure  may  occur  in  any  of  the 
stages.     (This  has  already  been  referred  to.)     The  tendency  to  spon- 


TUBERCULOSIS  359 

taneous  cure,  however,  is  so  variable  that  it  is  questionable  if  one  should 
depend  upon  it  in  any  individual  case.  The  tuberculous  focus  is  a 
menace  to  the  individual,  and  for  this  reason  should  be  treated  early. 


DISSEMINATED  MILIARY  TUBERCULOSIS. 

Two  factors  are  essential  in  the  production  of  disseminated  tuber- 
culosis: first,  the  presence  of  an  old  tuberculous  focus  in  some  part 
of  the  body,  and,  second,  the  involvement  in  this  focus  of  some  part 
of  the  blood  or  lymph  circulation.  If  these  two  factors  are  present, 
provided  that  the  tubercle  bacilli  have  gained  access  to  the  circulating 
lymph  or  blood,  numerous  metastatic  foci  of  tubercles  may  spring  up 
simultaneously  in  different  parts  of  the  body.  Any  of  the"  blood  or 
lymph  vessels  may  form  the  point  of  entrance.  Arteries  were  formerly 
believed  to  enjoy  a  special  immunity  from  tuberculous  infection;  more 
recently  this  has  been  found  to  be  an  error,  since  it  has  been  shown 
that  tubercles  occur  on  the  intima  of  both  arteries  and  veins,  usuallv  as 
a  result  of  direct  infection  from  an  overlying  focus.  The  thoracic  duct 
may  be  the  seat  of  tuberculous  lesions,  the  infection  being  conveyed 
to  it  by  the  lymphatic  vessels  coming  from  the  retroperitoneal  or  medi- 
astinal lymph  nodes.  Particles  of  caseous  material  sometimes  gain 
access  to  the  thoracic  duct,  and  these  particles  may  be  carried  into 
the  subclavian  vein,  eventually  into  the  pulmonary  circulation,  and  a 
consequent  pulmonary  infection  results.  It  has  not  infrequently  hap- 
pened that  tubercle  bacilli  have  gained  access  to  the  general  circulation 
during  an  operation  on  some  tuberculous  lesion.  This  has  occurred 
most  frequently  in  the  operations  on  tuberculous  nodes  of  the  neck, 
resections  of  the  joints,  and  operations  for  tuberculous  osteomyelitis. 
Large  doses  of  tuberculin,  particularly  during  the  first  era  of  its  use, 
produced  generalized  tuberculosis,  inasmuch  as  latent  foci  were  ren- 
dered active.  A  case  of  disseminated  tuberculosis,  when  at  its  height, 
may  involve  any  or  all  of  the  organs  of  the  body. 

Pathology. — Miliary  tubercles  found  in  various  parts  of  the  body  tend 
to  keep  pace  with  one  another  so  far  as  their  growth  is  concerned. 
Comparing  the  tubercles  in  a  portion  of  an  organ  with  another  portion 
of  the  same  organ,  they  seem  to  be  about  of  the  same  age.  This  holds 
good,  too,  when  the  tubercles  in  one  organ  are  compared  with  the 
tubercles  in  another  organ.  Microscopically,  they  do  not  show  any 
differences  from  the  tubercles  which  are  found  in  localized  tubercu- 
losis, with  the  exception  that  the  fibrous  capsule  about  the  miliary 
tubercle  is  very  thin  and  free  from  lime-salts  and  the  tubercle  does 
not  tend  to  liquefy  in  its  centre.  This  is  undoubtedly  due  to  the  rapid 
course  which  the  disease  usually  pursues.  If  it  is  subacute  or  chronic, 
the  individual  tubercles  may  attain  a  large  size.  As  a  rule,  the  tubercles 
are  small — about  the  size  of  a  millet-seed;  hence  the  term  "miliary 
tuberculosis."  The  individual  tubercles  are  firm  in  consistency;  they 
are  normally  of  a  gray  color;  though  in  the  lungs,  spleen,  and  the  liver 


300  INFECTIOUS  DISEASES 

they  sometimes  appear  yellowish.  As  a  rule,  the  oldest  and  largest 
tubercles  are  found  in  the  lung,  and  the  middle  and  lower  portions 
are  most  affected.  The  external  surface  is  dark  red,  granular  in 
appearance,  and  the  examining  finger  perceives  little  hard  masses 
which  feel  like  bird-shot.  On  cut-section  the  hmgs  are  bloody  and 
contain  little  air.  The  tubercles  are  very  numerous,  and  al)out  each 
one  is  a  small,  somewhat  granular,  dark  area  which  is  in  the  nature  of 
a  pneumonic  infiltration.  Careful  investigation  often  reveals  small 
tubercles  on  the  intima  of  the  veins.  The  liver,  spleen,  and  kidneys, 
upon  careful  examination,  show  numerous  miliary  tubercles.  In  .some 
cases  tubercles  of  liver  and  kidneys  are  most  distinct  in  the  capsule. 
Their  presence  in  the  organ  is  elicited  with  .some  difficulty  on  account 
of  the  parenchymatous  degeneration.  The  spleen  is  always  eidarged; 
the  liver  and  kidneys  also  are  usually  increased  in  size.  This  is 
because  of  the  parenchymatous  degeneration  occurring  in  these 
organs. 

Tubercles  are  very  frequently  found  in  the  choroid;  it  has  been  esti- 
mated in  75  per  cent,  of  the  cases.  This  is  probably  due  to  the  extreme 
vascularity  of  this  tissue. 

Etiology. — Debilitated  conditions,  from  whatever  cau.se,  predispose  to 
the  development  of  miliary  tuberculosis  in  children.  The  disease  is 
especially  frecpient  after  the  acute  infectious  diseases,  particularly 
those  which  are  associated  with  bronchitis.  It  should  not  be  con- 
sidered that  these  acute  infectious  diseases  act  in  a  direct  causal 
manner.  From  a  study  of  all  the  facts  it  would  seem  that  these  acute 
infectious  diseases  caused  old  latent  foci  of  tuberculosis  to  become 
active.  Poor  food,  bad  hygiene,  and  malnutrition  are  undoul)tedly 
predisposing  causes.  Numerous  cases  are  recorded  where  children 
fell  ill  with  miliary  tuberculosis  after  operations  or  injuries,  particu- 
larly those  which  disturbed  old  or  latent  tuberculous  foci  in  bones  or 
joints.  It  is  interesting  to  note,  though  difiicult  to  explain,  the  great 
fre(iuency  of  this  disease  in  children  as  compared  with  adults.  In 
adults  affected  with  tuberculosis  the  chronic  form  is  the  most  frequent. 
This  variety  is  rare  in  children.  On  the  other  hand,  miliary  tubercu- 
losis is  somewhat  rare  in  adults  as  compared  to  the  chronic  form.  Carr, 
who  examined  120  cases  of  tuberculosis  in  infants,  found  that  S2  were 
of  the  disseminated  miliary  variety.     (See  Plate  VIII.) 

Symptoms. — Miliary  tuberculosis  occurs  with  relative  frequency 
during  infancy  and  childhood.  From  what  has  already  been  said 
concerning  the  pathology  of  this  disease,  it  is  clear  that  the  original 
focus  of  tuberculosis  may  have  been  latent  in  the  organism  for  a  con- 
siderable time  before  the  general  infection  occurred.  The  infection 
may  have  originated  from  affected  bronchial  or  mesenteric  lymph 
nodes.  Probably  next  in  frequency  are  caseous  foci  in  the  lungs; 
less  often  than  the  foregoing  is  a  thickened,  pleuritic  exudate,  tuber- 
culous in  nature.  Local  processes  in  the  bones  and  joints  may  cause 
the  general  infection.  Chronic  tuberculous  processes  of  the  mucous 
membranes,  respiratory  or  digestive  tract,  may  lead  to  di.sseminated 


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TUBERCULOSIS  361 

tuberculosis.  In  rare  instances  no  primary  tuberculous  focus  can  be 
demonstrated  on  autopsy.  In  these  cases  it  must  be  assumed  that 
general  infection  has  occurred  from  the  exterior,  without  focal  lesion. 

Three  clinical  forms  of  miliary  tuberculosis  may  be  distinguished 
in  children:  (1)  that  variety  which  for  the  first  part  of  its  course 
resembles  marasmus  in  infants;  (2)  the  pneumonic,  and  (3)  the  typhoid 
form. 

1.  The  Tnarantic  type  is  peculiar  to  infants.  The  disease  begins  insidi- 
ously. If  these  infants  are  systematically  weighed  it  is  observed  that 
they  lose  in  body  weight,  more  in  acute,  less  in  protracted  cases.  All 
of  these  children  become  thin,  pale,  and  weak.  At  the  very  first  the 
appetite  is  undisturbed  and  the  digestive  apparatus  presents  no  symp- 
toms. The  child  may  continue  in  this  condition  for  weeks  or  months 
before  any  manifest  symptoms  of  the  disease  appear,  but  the  process 
continues.  The  marasmus  becomes  more  manifest.  As  the  disease 
progresses,  disturbances  of  function  occur;  at  times  the  child  shows  loss  of 
appetite,  at  other  times  the  appetite  is  voracious.  Often  it  presents 
dyspeptic  symptoms  like  vomiting  and  diarrhea,  or  during  the  course 
of  the  disease  it  may  be  obstinately  constipated.  In  the  same  way 
the  menta,l  state  varies;  the  child  may  be  apathetic  and  fretful,  or  it 
may  become  irritable.  The  duration  of  the  period  of  latency  depends 
on  the  rapidity  with  which  the  tubercles  grow,  their  location,  and  the 
intensity  of  the  intoxication. 

After  the  disease  has  persisted  for  a  time,  temperature  is  observed. 
First  there  may  be  evening  exacerbation,  the  temperature  may  rise  to 
37.9°  to  38.2°  C.  (100°  to  100'.°  R),  or  a  constant  fever  may  set  in, 
varying  from  37.9°  to  39°  C.  (100°  to  102°  F.).  About  this  time,  too, 
local  symptoms  may  appear.  The  lung  is  frequently  the  first  to  be 
involved.  Sometimes  the  infants  cough,  or  there  may  be  heard  upon 
auscultation  a  few  moist  rales;  or  they  may  have  pains  in  the  chest, 
though  the  symptoms  are  strikingly  disproportionate  to  the  physical 
findings.  Respirations  are  frequent,  varying  from  60  to  90  per  minute. 
Vomiting  and  diarrhea  occur. 

Under  the  influence  of  the  increasing  fever  and  the  general  loss  in 
strength,  children  may  die  as  a  result  of  exhaustion,  the  disease  having 
run  the  course  of  a  marasmus.  The  closing  scene  may  be  caused  by 
pulmonary  involvement;  more  rarely,  symptoms  of  meningitis  may 
occur  and  rapidly  terminate  the  disease.  Before  death  small  pur- 
puric spots  may  appear  over  the  abdomen  and  extremities. 

The  physical  and  clinical  findings  of  this  type  of  the  disease  remain 
very  meagre  until  shortly  before  death.  INIarasmus  may  begin  in  these 
patients  before  any  gross  anatomical  changes  have  occurred  in  the 
organs.  In  some  children  who  have  died  from  infectious  diseases  no 
miliary  tubercles  have  been  found,  though  tubercle  bacilli  were  isolated 
from  the  tissues.  As  the  disease  progresses  the  tubercles,  though  they 
attain  their  maximum  size,  are  not  large  enough  of  themselves  to  pro- 
duce physical  signs.  In  the  lungs  the  complicating  emphysema  makes 
the  detection  of  small  pneumonic  areas  diflicult.     The  auscultatory 


3G2 


IXFECTIO I  \S  DISK.  1 SES 


findings  are  those  of  l)ronchoj)ncunionia.      "^riio  liver  and  spleen  are 
nearly  always  (Mdar<;e(l. 

2.  The  jyneuntofiic  jonn  is  most  often  eneountered  in  children  from 
the  second  to  the  fifth  year.  It  may  occur  as  a  terminal  form  in  the 
marantic  tui)erculosis.  It  most  often  follows  an  attack  of  acute  bron- 
chitis occasioned  by  whooping-coujih  or  measles.  It  may  be  preceded 
by  a  prolonijjed  period  of  malaise  or  p^radual  wasting,  or  its  onset  may 
be  very  abruj)t  without  any  prodromata  whatever.  When  it  follows 
an  infectious  fever,  such  as  measles,  the  symptoms  may  arise  so  early 
as  to  make  it  impossible  to  distinguish  the  end  of  one  from  the  begin- 
ning of  the  other;  at  other  times  there  is  a  febrile  jxM'iod  of  several 
weeks  between  the  two  diseases.  The  symptoms  of  the  pneumonic 
form  are  exactly  those  of  an  acute  bronchopneumonia.  The  fever 
ranges  from  39.5°  to  40.5°  C.  (103°  to  105°  R),  the  pulse  is  accelerated, 
respirations  increase  gradually  until  they  reach  70  or  80  per  minute,  the 
child  is  somewhat  cyanotic,  and  extreme  dyspnea  occurs.  The  physical 
findings  are  very  few  at  the  onset;  they  are  those  which  occur  in  diU'use 
bronchitis;  later,  the  respirations  become  broncho  vesicular  or  bronchial 


Fig.  72 


^  -1 — r-1— ^-t- 


Temperature  chart  in  typhoid  form  of  miliary  tuberculosis. 

in  small  areas,  crepitant  rales  are  heard,  and  there  is  more  or  less 
impairment  of  resonance.  The  most  common  site  of  invasion  is  the 
middle  of  the  right  lung,  but  the  rales  are  not  limited  to  this  area. 
As  a  rule,  the  physical  findings  are  very  few  until  near  the  termination 
of  the  disease.  Death  occurs  in  ten  days  or  two  weeks  in  most  cases, 
though  at  times  the  disease  is  more  protracted.  Symptoms  of  tubercu- 
lous meningitis  usually  appear  at  the  close  of  the  disease. 

3.  The  Typhoid  Form. — This  form  usually  appears  in  children  above 
six  years  of  age.  It  is  preceded  by  a  period  of  unaccountable  wasting. 
Anemia  and  digestive  disturbances,  such  as  anorexia,  nausea,  and  vomit- 
ing, may  be  prodromal  symptoms.  Or,  fever  of  a  low  grade  may  set 
in  abruptly;  it  rapidly  rises  and  assumes  a  continuous  type  (Fig.  72). 
The  picture  closely  resembles  typhoid  fever.  I^ocalizing  manifesta- 
tions, as  pain  and  dyspnea,  are  entirely  absent.  After  ten  days  or 
two  weeks  focal  symptoms  begin  to  appear,  most  often  in  the  lungs. 
The  rales,  which  were  at  first  diffuse,  become  most  abundant  at  one 
or  two  spots.  The  respiratory  sounds  may  at  a  few  points  gradually 
assume  a  bronchial  type.    The  fluctuations  in  temperature  are  usually 


TUBERCULOSIS  363 

greater  than  in  typhoid  fever.  As  the  time  arrives  for  the  child  to  improve 
from  typhoid,  the  temperature  may  abate,  but  the  child  continues  to 
waste  and  becomes  cachectic.  Usually  the  case  terminates  as  a  tuber- 
culous bronchopneumonia  or  meningitis. 

Diagnosis. — The  physical  findings  of  the  typhoid  form  are  practicallv 
none  for  the  first  ten  days  or  two  weeks;  there  may  be  diffuse  rales  over 
both  lungs;  the  spleen  may  or  may  not  be  palpable;  the  urine  may 
contain  albumin  or  a  few  hyaline  casts.  Ehrlich's  diazo  reaction  occurs 
as  regularly  in  miliary  tuberculosis  as  in  typhoid,  and,  therefore,  is  of  no 
value  in  the  differential  diagnosis.  A  roseola  may  occur,  but  not  so 
often  as  in  typhoid  fever.  Late  in  the  disease  the  local  findings  clear 
up  the  diagnosis — bronchopneumonia  or  meningeal  manifestations 
point  with  great  probability  to  tuberculosis.  Periods  of  temporary 
improvement  followed  by  relapse  and  continuous  wasting  are  also 
characteristic.    The  Grtiber-Widal  reaction  has  been  found  very  rarely. 


TUBERCULOSIS  OF  THE  LUNGS. 

The  fact  has  already  been  referred  to  that  the  bronchial  lymph  nodes 
are  first  to  be  affected  in  young  infants  and  children;  the  tuberculous 
process  extends  from  these  lymph  nodes  directly  to  the  lungs  in  most 
cases.  For  this  reason  the  middle  and  lower  portions  of  the  lung  are 
the  most  frequent  seat  of  the  tuberculous  infection. 

Etiology. — Tuberculosis  of  the  lungs  in  children  may  occur  as  a 
diffuse  or  a  localized  disease.  The  diffuse  form  is  usually  acute  in  its 
course  and  is  almost  always  the  terminal  manifestation  of  a  general 
miliary  tuberculosis  throughout  the  body. 

In  young  infants  the  diffuse  form  may  manifest  itself  by  great  wasting. 
This  is  spoken  of  as  the  marantic  variety,  and  has  been  already  described. 
Fever  may  or  may  not  be  present;  when  present  it  is  irregular  in  type. 
In  children  of  two  to  four  years  the  pulmonary  S}Tnptoms  appear  after 
a  protracted  typhoid-like  fever. 

!Many  of  the  acute  infectious  diseases,  such  as  pertussis,  measles, 
acute  bronchitis  or  bronchopneumonia  (especially  if  there  have  been 
repeated  attacks),  offer  a  favorable  soil  for  the  development  of  tubercu- 
losis, particularly  of  the  bronchopneumonic  form.  The  tuberculosis 
may  appear  immediately  or  shortly  after  one  of  these  infections.  Primary 
tuberculous  disease  of  the  bones,  skin  or  genitourinary  organs  may 
also  give  rise  to  a  tuberculous  bronchopneumonia. 

Tuberculous  Bronchopneumonia. — Tuberculous  bronchopneumonia 
may  be  arbitrarily  divided  according  to  its  duration  into  three  classes: 
1.  The  acute  form,  lasting  less  than  one  month.  2.  The  subacute  form, 
one  to  three  months.     3.  The  chronic  form. 

Symptomatology. — The  acute  variety  resembles  in  its  course  and 
physical  findings  simple  bronchopneumonia.  The  onset  is  sudden,  or 
it  may  follow  one  of  the  acute  infectious  diseases  already  mentioned. 
The  prostration  is  marked;  the  cough  becomes  more  and  more  severe 


364  INFECTIOUS  DISEASES 

as  the  disease  progresses.  In  infants  and  young  children  (in  whom  this 
type  is  most  common)  there  is  no  expectoration.  Dyspnea  is  a  marked 
symptom  with  GO  to  SO  respirations  per  minute;  cyanosis  and  a  weak, 
rapid  pulse  are  nearly  always  present;  the  fever  is  irregular  and  rela- 
tively low,  100°  to  104°  F.  (37.9°  to  40°  C);  a  persistently  high  temper- 
ature is  unusual.  The  physical  signs  are  found  in  all  parts  of  the  lungs; 
they  are  unexpectedly  meagre,  as  compared  to  the  marked  prostration 
presented  by  the  child.  There  may  or  may  not  he  slight  dulness,  whic-li 
is  usually  pronounced  in  the  upper  part  of  the  lower  lobes  (corresponding 
to  tlie  hilus  of  the  lungs);  the  vocal  fremitus  and  voice  sounds  may  be 
exaggerated  in  the  same  regions,  and  small,  dry  and  moist  rales  are 
numerous  everywhere.  The  disproportion  between  the  severe  symptoms 
and  the  slight  physical  signs  is  a  striking  feature  of  the  disease.  The 
course  is  rapidly  and  progressively  downward,  the  cough  and  cyanosis 
increasing  to  the  end.  In  the  last  days  symptoms  of  meningeal  involve- 
ment may  predomiruite. 

The  subacute  form  Is  most  frequent  in  young  children.  Like  the 
acute  form  above  described  it  may  be  part  of  a  disseminated  tuber- 
culosis, or  it  may  follow  any  acute  infection  of  the  respiratory  tract. 
If  the  latter  is  the  case,  the  onset  may  be  obscured  for  a  time  and  its 
course  will  depend  chiefly  on  the  concomitant  non-tuberculous  broncho- 
pneumonia. When  arising  as  an  independent  disease  or  in  the  course 
of  miliary  tuberculosis,  it  usually  appears  as  an  acute  bronchitis  or 
bronchopneumonia,  and  differs  from  the  acute  tuberculous  form  chiefly 
in  its  protracted  course  and  in  its  remissions  and  exacerbations.  The 
prostration  is  not  so  severe;  the  cyanosis  and  dyspnea  are  less  marked. 
When  the  associated  non-tuberculous  inflammation  subsides  a  period 
of  remission  begins;  now,  the  areas  of  tuberculous  consolidation  may- 
be demonstrai)le,  because  in  this  more  protracted  form  they  attain 
a  greater  size.  After  the  acute  infectious  diseases  the  symptoms  of 
tuberculous  bronchopneumonia  may  begin  before  the  child  has  regained 
a  normal  temperature,  or  there  may  be  a  short  afebrile  interval.  The 
disease  begins  like  an  acute  bronchitis  or  an  ordinary  bronchopneumonia, 
and  cannot  l)e  distinguished  from  such  by  any  signs  or  symptoms. 
At  the  end  of  two  or  three  weeks  the  symptoms  abate  and  the  signs 
become  less  pronounced,  but  never  entirely  disappear.  There  is  soon 
a  recurrence,  which  is  more  severe  than  the  first  attack.  Exacerbations 
alternate  with  remissions  until  finally  the  terminal  picture  of  the  acute 
tuberculous  bronchopneumonia  is  produced.  At  times  the  disease 
may  he  simply  progressive,  without  remissions  and  exacer])ations  and 
without  diminution  of  the  physical  signs  until  the  fatal  termination. 
This  form  diflFers  from  the  acute  form  only  in  being  less  rapid  in  its 
course.  The  wasting  is  extreme;  lost  weight  is  never  regained,  although 
there  may  be  at  times  interruptions  in  the  progressive  emaciation. 

I'he  fever  depends  chiefly  on  the  pulmonary  complications,  which 
are,  for  the  most  part,  simple  bronchitis  and  non-tuberculous  broncho- 
pneumonia. The  period  of  remission  may  be  afebrile,  or  a  low  range 
of  temperature  may  persist.     During  the  acute  attaclvs  the  fever  is 


TUBERCULOSIS  365 

irregular,  rarely  hectic,  and  not  often  persistently  high.  Gastrointestinal 
symptoms,  as  anorexia, vomiting,  and  diarrhea,are  usually  present ;  in  some 
cases  these  symptoms  may  be  due  to  amyloid  changes.  Secondary  anemia 
and  cachectic  edema  are  frequently  present  in  the  last  stages  of  the  disease. 

In  the  lungs  small  areas  of  dulness  are  found  most  often  in  the  upper 
part  of  the  lower  lobes.  Bronchophony  or  bronchial  breathing  with 
crepitant  and  subcrepitant  rales  are  the  usual  auscultatory  findings; 
sometimes  the  examination  shows  the  evidence  of  an  acute  diffuse 
bronchitis.  The  spleen  and  liver  are  usually  palpable  and  soft,  unless 
they  are  the  seat  of  amyloid  deposits  arising  from  old  tuberculous 
lesions  in  other  parts  of  the  body;  in  the  latter  case  the  spleen  and  liver 
are  also  palpable,  but  hard,  not  soft. 

The  chronic  tuberculous  'pneimwnia  appears  most  often  in  children 
over  five  years  of  age,  and  approaches  the  type  commonly  present  in 
adults.  The  areas  of  consolidation  due  to  the  tuberculous  lesion  are 
extensive,  and  cavities  may  form,  although  from  their  small  size  they 
may  be  difficult  to  detect,  as  they  do  not  always  show  characteristic 
signs.  The  symptoms  may  appear  gradually  with  slowly  increasing 
severity,  or  may  begin  like  the  acute  or  subacute  forms,  continuing 
with  repeated  exacerbations  and  remissions.  The  findings  are  those  of  a 
bronchitis,  pleurisy,  lobar  pneumonia  or  bronchopneumonia  during  the 
more  acute  phases  of  the  disease.  In  the  interval  they  do  not  entirely 
disappear;  the  child  remains  sickly  and  anemic.  ^  Cachexia  is  observed 
in  a  certain  proportion.  During  this  stage  of  quiescence  signs  are 
variable,  but  remain  confined  to  the  chief  points  of  tuberculous  involve- 
ment. They  are  found  most  often  in  the  upper  lobes,  rarely  at  the  very 
apices  of  the  lungs;  next  in  frequency  in  the  upper  portions  of  the 
lower  lobes.  Externally  the  changes  are  best  demonstrated  anteriorly 
in  the  mammary  region  or  posteriorly  between  the  scapulre.  They 
are  characteristic  of  circumscribed  bronchitis,  bronchopneumonia  or, 
very  rarely,  of  cavity  formation.  As  stated  above,  the  cavities  are 
seldom  large  enough  to  produce  definite  signs,  such  as  amphoric  breath- 
ing, large  bubbling  rales,  Skoda's  tympany,  Wintrich's  sign,  which  is 
a  change  in  pitch  of  the  percussion  note  when  the  mouth  is  opened  and 
closed,  or  cracked-pot  resonance.  Any  one  or  all  of  these  signs  may 
be  due  to  an  area  of  consolidation  about  a  large  or  dilated  bronchus. 

During  the  exacerbations  the  signs  become  less  characteristic  of 
tuberculosis  and  correspond  to  associated  inflammatory  changes.  The 
condition  then  becomes  that  of  a  diffuse  bronchitis  with  large  and 
small  dry  and  moist  rales,  or  of  lobar  pneumonia  or  bronchopneumonia. 
It  is  rarely  possible  by  examination  during  this  stage  to  localize  the  foci 
of  tuberculosis  or  to  distinguish  the  disease  definitely  from  a  pneumo- 
coccus  infection. 

The  duration  of  the  disease  varies  from  months  to  years.  The 
wasting  is  progressive,  though  the  symptoms  abate  in  periods.  Usually 
there  have  been  repeated  attacks  of  bronchitis  or  bronchopneumonia 
before  the  true  nature  of  the  infection  is  revealed.  The  persistence  of 
physical  signs  during  the  interval,  with  occasional  rises  in  temperature, 


366  INFECTIOUS  DISEASES 

is  suggestive  of  tuberculosis.  Hemoptysis  does  not  occur  often  in  chil- 
dren; when  present,  the  hemorrhage  is  small  in  amount  and  very  rarely 
proves  fatal.  Death  results  from  miliary  tuberculosis,  cachexia,  simple 
or  l)ronchopneumonia,  or  from  meningeal  tuberculosis. 

Couf/h  in  young  children  is  very  seldom  accompanied  by  expectora- 
tion, and  many  means  have  l)een  devised  to  obtain  sputum  for  diag- 
nostic purposes.  A  method  of  procuring  sputum  by  irritating  the 
epiglottis  and  catching  the  mucus  on  a  gauze  sponge  in  the  pharynx 
has  already  been  referred  to  under  Diagnosis  of  Tuberculosis.  Holt 
reconunends  the  passage  of  a  stomach  tube  and  examination  of  the 
mucus  attached  to  it,  because  a  portion  of  it  may  be  the  sputum  swal- 
lowed by  the  child. 

Tuberculin  injections  may  prove  of  value  in  diagnosis  in  older 
children,  especially  during  afebrile  periods  of  the  chronic  form  of  the 
disease.     As  stated  before,  its  use  is  not  devoid  of  danger. 

Chronic  localized  tuberculosis,  or  phthisis,  so  frecjuent  in  adults,  is  rarely 
found  in  young  children,  and  is  not  common  before  the  tenth  or  twelfth 
vear.  It  does  not  differ  in  its  pathology  or  symptoms  from  the  disease 
in  older  persons,  except  that  its  progress  is  usually  more  rapid.  The 
child  has  frefpient  "colds,"  a  cough  that  is  rarely  entirely  absent;  it  is 
pale,  weak,  and  presents  an  increasing  cachexia.  Fever  is  usually 
present,  either  continuous  and  of  low  grade,  or  during  the  bronchitis 
attacks  the  fever  may  be  of  a  hectic  type.  There  may  or  may  not  be 
pain  in  the  chest.  Foci  of  dulness  are  found  in  the  lungs  associated 
with  bronchial  or  V^roncliovesicular  breathing  and  rales  ranging  from 
mucous  clicks  to  large  moist  sounds.  Bronchophony  is  frequently 
present.  Cavities  may  occur  and  are  recognized  by  amphoric  breathing, 
cracked-pot  resonance,  Wintrich's  sign,  and  the  other  characteristic 
findings.  The  apices  of  the  upper  lobes  and  the  bases  of  the  lower 
are  usually  spared.  Perforation  of  the  lung  with  production  of  a  pyo- 
pneumothorax is  rare  in  children,  as  are  profuse  hemorrhages,  though  the 
latter  do  occur. 

TREATMENT  OF  TUBERCULOSIS. 

Prophylaxis. — It  has  already  been  sufficiently  emphasized  that  con- 
tact infection  is  the  most  prolific  source  of  the  spread  of  tuberculosis. 
For  this  reason  it  is  of  prime  importance  that  healthy  individuals  should 
avoid,  as  far  as  possible,  contact  with  those  who  are  tuberculous,  par- 
ticularly those  who  are  suffering  from  an  active  pulmonary  form.  A 
healthy  individual  should  not  occupy  the  same  sleeping  apartment  with 
one  who  is  suftering  from  tuberculosis.  Lactation  is  absolutely  contra- 
indicated  in  cases  where  the  mother  is  suffering  from  tuberculosis.  This 
is  true  whether  the  mammary  glands  are  involved  or  not.  The  best 
possible  hygienic  conditions  should  be  provided.  The  food  should 
be  most  carefully  adapted  to  the  varying  needs  of  the  mother  and  child. 
In  families  where  a  predisposition  to  tuberculosis  exists,  every  possible 
precaution  should  be  taken  to  prevent  the  occurrence  of  the  acute  infec- 


TUBERCULOSIS 


367 


tious  diseases,  particularly  those  which  are  associated  with  secondary 
bronchitis.  Wherever  it  is  possible,  precaution  should  be  taken  to 
prevent  attacks  of  primary  bronchitis.  This  latter  may  be  sometimes, 
though  not  always,  accomplished  by  proper  ventilation,  avoidance  of 
irritating  dust  in-doors  and  out -doors,  and  by  prompt  and  early  atten- 
tion to  the  slight  catarrhal  infections,  which  frequently  proceed  down- 
ward, causing  successively  pharyngitis,  laryngitis,  and  bronchitis.  The 
enlarged  tonsils  and  adenoids  or  other  affections  causing  obstruction  to 
nasal  breathing  should  receive  prompt  treatment.  Life  in  the  open  air, 
frequent  bathing,  followed  by  cold  or  tepid  sponging,  increases  the 
resistance  against  infection.  Open-air  exercise  which  is  directed  par- 
ticularly to  the  development  of  the  thorax  and  to  the  expansion  of  the 
lungs  is  also  of  value  in  preventing  infection.  Those  children  who 
are  under  weight  or  undersized  should  be  encouraged  to  take  an 
abundance  of  nutritious  food,  especially  fat,  and  should  be  given  cod- 
liver  oil,  and  if  indicated,  stomachics  or  iron  tonics  for  the  purpose  of 
improving  the  general  health. 

The  use  of  milk  or  meat  from  tuberculous  animals  should  be  avoided, 
if  this  is  possible.  If  the  source  of  the  milk  used  is  not  known,  heating 
at  65°  C.  (149°  F.)  for  fifteen  minutes  is  effective  in  destroying  tubercle 
bacilli  contained  therein  (Theobald  Smith).  The  immunization  of 
cattle  by  Behring's  method  of  injecting  increasing  doses  of  tubercle 
bacilli  derived  from  man  will  probably  prove  of  value  in  removing  the 
danger  of  bovine  infection.  Behring  believes  also  that  it  may  be  of 
benefit  to  feed  infants  on  milk  from  immune  cows,  and  that  this  pro- 
cedure may  confer  upon  them  a  certain  degree  of  immunity. 

The  sputum  and  other  excreta  of  tuberculous  individuals  should  be 
disinfected.  The  sputum  is  not  only  dangerous  to  others,  but  to  the 
patient  as  well,  since  it  subjects  him  to  the  possibility  of  reinfection. 
Nor  should  the  sputum  be  swallowed,  as  this  is  so  often  the  cause  of 
intestinal  tuberculosis.     In  infants  this  danger  cannot  be  avoided. 

Therapeusis. — There  is  no  specific  treatment.  Favorable  results 
have  been  published  from  the  use  of  Koch's  new  tuberculin.  The 
tubercuhn,  however,  is  not  at  all  suitable  for  advanced  cases. 

The  best  results  are  obtained  by  fortifying  the  general  health  and 
relieving  the  symptoms  as  they  arise.  For  the  first  purpose  every  effort 
should  be  made  to  increase  the  body  weight.  This  can  be  best  accom- 
plished by  an  abundance  of  wholesome,  easily  digested  food  and  by 
the  use  of  cod -liver  oil.  It  should  not  be  given,  however,  if  its  admin- 
istration produces  gastric  disorders  or  diminishes  the  appetite.  Other 
oils  and  fats  may  be  administered  as  substitutes.  The  syrup  of  the  iodide 
of  iron  and  Fowler's  solution  are  extensively  used  for  their  tonic  effects. 

Changes  of  climate  have  proven  of  value  not  only  in  cases  of  pulmonary 
tuberculosis,  but  also  in  others  of  long  standing,  especially  of  the  bones, 
glands,  and  lymph  nodes.  High  and  dry  air  is  most  strongly  recom- 
mended when  the  lungs  and  bones  are  involved,  while  the  sea  air  in 
a  warm,  equable  climate  appears  best  for  cases  of  disease  of  the  lymph 
nodes. 


368  INFECTIOUS  DISEASES 

For  those  iiKlividuals  who  cannot  remain  away  permanently,  it  is 
not  advisable  that  a  too  radical  change  in  climate  he  made.  For  instance, 
a  sojourn  of  six  weeks  during-  Jamiary  and  February  in  ('alit'ornia, 
and  then  a  return  to  the  severe  March  weather  of  the  Middle  West  or 
East  will  not  accomplish  good  results.  Too  great  ditierences  in  climatic 
conditions  are  likely  to  cause  reinfection  and  rapid  progress  of  the 
disease.  The  most  desirable  high  climates  are  those  of  Arizona,  New 
Mexico,  and  Colorado.  The  coa^sts  of  Florida  and  Texas  are  warm  and 
moist.  For  moderate  change  and  moderate  elevation,  good  results  are 
obtained  in  the  Adirondack's  and  Catskills.  The  region  to  be  sought 
depends  on  the  season  and  the  climate  of  the  country  in  which  the 
disease  is  being  treated.  Extreme  changes  should  Ijc  avoided.  In  the 
summer,  mountain  air  shoukl  be  selected.  In  winter,  a  southern  region 
is  chosen  by  preference.     Sunshine  is  always  to  be  sought  for. 

Rest  in  bed  is  essential  in  the  treatment  of  cases  with  a  temperature 
of  more  than  37.9°  C.  (100°  F.).  Otherwise,  moderate  exercise  is  pre- 
ferable. The  room  in  which  the  patient  remains  should  have  all  the 
windows  open  and  as  much  sunlight  as  possible.  INIany  sanatoria  are  so 
arranged  that  the  patients  with  fever  can  spend  their  entire  days  and 
nights  in  the  open  air. 

Treatment  of  Lymphadenitis. — The  prophylactic  antl  general  hygienic 
considerations  which  have  already  been  discussed  apply  to  the  treat- 
ment of  tuberculous  lymphadenitis.    It  cannot  be  too  frequently  empha- 
sized that  children  suffering  from  local    tuberculosis  should   have  an 
abundance  of  fresh  air  and  sunshine  throughout  the  whole  year.     Chil- 
dren with  tuberculous  nodes  frequently  show  improvement  if  they  are 
sent  to  the  seashore  for  a  protracted  stay,  or  to  the  country  for  the 
summer.     The  nutrition  should  be  maintained,  and  as  far  as  is  com- 
patible with  the  digestive  functions,  they  shoidd  be  rather  overfed  than 
underfed.      Internally,  the  various  tonics  are  in(licate<l — cod-liver  oil 
and  the  syrup  of  the  iorlide  of  iron  are  the  most  valuable.      Fowler's 
solution,  preparations  like  the  albuminate  or  peptonatc  of  iron,  syrup 
of  hydriodic  acid  aid  the  general  nutrition,  increase  the  resistance  of 
the  patient,  and  sometimes  seem  to  cause  an  itivolution  of  the  nodes. 
If  the  nodes  are  localized,  as  in  the  cervical  region,  various  external 
applications,  such  as  mercurial  ointment,  or  the  iodine  preparations, 
as  the  tincture  and  the  compound  ointment,  have  been  recommended. 
These  external  applications  have   no   therapeutic  value  and   their  use 
should  be  discouraged.     In  the  treatment  of  tuberculous   nodes   which 
lie    superficially    the    a*-ray    treatment    has    been    advised,    and    has 
undoubtedly  been  successful  in  some  cases.     In  that   form  of  tubercu- 
losis of  the  lym])h  nodes  which  closely  resembles  pseudoleukemia,  and 
which    has   been   alluded   to  as  generalized    tuberculosis  of  the  lymph 
nodes,  the  same  method  of   treatment  should  be  followed  as  has   pre- 
viously been   outlined.      In  addition,  arsenic,  as   in  Fowler's  solution, 
may  be  employed   in  increasing  doses,  by  mouth  or  hypodermically. 
The  x-ray  treatment  is  recommended  also  in  this  form  of  tuberculosis. 
In  this  latter  class  of  cases  extirpation  of  the  nodes  does  more  harm 


TUBERCULOSIS 


369 


than  good.  The  nodes  recur  after  the  operation  and  the  growth  is 
more  rapid  after  the  extirpation  than  before.  In  the  local  tuberculosis 
of  lymph  nodes,  which  shows  a  tendency  to  increase,  surgical  inter- 
vention is  indicated,  but  all  such  cases  should  have  the  benefit  of  out- 
of-door  life  before  operation  is  insisted  upon. 


TUBERCULOSIS  OF  THE  INTESTINE  AND  MESENTERIC  LYMPH 

NODES. 

By  DAVID  BOVAIRD,  Jr.,  M.D. 

Tuberculosis  of  the  intestine  and  mesenteric  lymph  nodes  practically 
always  occur  together  and  they  are  therefore  considered  in  conjunction. 

Etiology. — Tuberculosis  of  the  alimentary  tract  may  possibly  be 
produced  by  the  lodgement  of  bacilli  floating  in  the  blood  stream,  the 
primary  focus  being  elsewhere  in  the  body,  but  such  spread  of  the 
disease  appears  to  be  relatively  rare.  In  the  great  majority  of  cases 
intestinal  tuberculosis  is  produced  by  bacilli  that  have  been  swallowed. 
These  bacilli  may  come  from  old  tuberculous  processes  in  the  lungs 
just  as  undoubtedly  happens  in  adult  intestinal  tuberculosis,  or  they 
may  be  taken  into  the  body  with  some  of  the  food,  the  first  tuberculous 
lesions  being  produced  in  the  intestinal  tract.  In  the  first  case  we  have 
a  secondary,  in  the  second  a  primary  intestinal  tuberculosis.  For  many 
years  a  great  deal  of  interest  has  centred  about  the  question  of  the 
frequency  of  such  primary  intestinal  tuberculosis  and  its  causation  by 
the  milk  of  tuberculous  cattle.  The  furore  created  by  Koch's  declaration 
that  human  and  bovine  tuberculosis  are  separate  and  different  diseases, 
and  that  })ovine  tul^erculosis  cannot  be  transmitted  to  man,  and  vice 
versa,  is  still  fresh  in  our  minds.  Both  before  and  since  the  time  of 
Koch's  address  many  papers  dealing  with  the  question  of  primary 
intestinal  tuberculosis  have  been  published  and  certain  very  discordant 
results  are  reported.  In  125  autopsies  on  tuberculous  children  I  foimd 
just  2  cases  of  apparently  primary  intestinal  lesion,  and  in  a  total  of 
369  cases  from  New  York,  this  number  including  also  the  observations 
of  Holt  and  Northrup,  there  were  5  cases  of  such  primary  intestinal 
infection,  a  little  more  than  1.3  per  cent.  With  these  figures  those  of 
German  and  French  observers  fairly  well  agree.  English  statistics, 
however,  present  a  radical  difference.  In  748  autopsies  on  tuberculous 
children,  collected  from  English  literature,  there  were  136,  or  18  per  cent., 
primary  intestinal  infections.  In  English  writings  the  percentage  of 
such  cases  is  generally  stated  to  be  as  high  as  28  to  30  per  cent.  It  is 
very  difficult  to  reconcile  these  figures.  It  cannot  be  done  on  the  basis 
of  proportionate  variation  in  the  amount  of  tuberculosis  in  cattle,  but 
the  fact  cannot  be  doubted  that  conditions  prevail  in  England  which 
are  radically  different  from  those  in  America. 

Investigations  have  shown  that  there  must  be  abundant  opportunities 
for  infection  from  the  milk  of  tuberculous  cattle>  tubercle  bacilli  having 
24 


370  INFECTIOUS  DISEASES 

been  found  in  as  high  as  25  per  cent,  of  samples  of  dairy  milk  supplied 
for  use  in  cities. 

It  should  not  be  forgotten  that  there  are  other  ways  in  which  children 
can  receive  and  swallow  tui:)ercle  bacilH.  Especially  is  it  possil)le  that 
children  living  in  homes  with  tuberculous  adults  should  be  infected  by 
kissing,  or  that  the  child's  hands  become  infected  in  playing  about  the 
floor  and  the  bacilli  be  in  this  way  carried  to  the  moutii.  It  has  been 
demonstrated  that  tubercle  bacilli  may  be  found  under  the  nails  of 
children,  even  when  there  is  no  tuberculosis  in  the  home. 

Doubtless  but  few  of  the  bacilli  swallowed  reach  the  intestine  in  a 
condition  to  tlo  harm,  otherwise  intestinal  tuberculosis  would  become 
vastly  more  common. 

Pathology.— Tuberculosis  of  the  intestine  and  mesenteric  lymph  nodes 
is  nearly  always  part  of  a  general  tuberculosis,  and  the  tuberculous 
lesions  are  found  in  the  bronchial  nodes  and  lungs,  the  liver,  spleen,  etc. 
Intestinal  lesions  are  found  in  a  consideral)le  percentage  of  all  cases 
of  tuberculosis  in  cliildren.  In  my  series  of  12.")  cases  there  were  intes- 
tinal lesions  in  30.  These  lesions  are  found  mainly  in  the  small  intestine, 
but  are  found  in  the  large  intestine  also.  In  the  earliest  stage  the  lesions 
are  miliary  tubercles;  small,  pale-yellow  grains,  about  a  line  in  diameter; 
they  may  be  felt.  They  are  usually  found  first  in  Peyer's  patches 
(Figs.  73  and  74).  There  may  l)e  only  a  few  or  great  numbers  of  them. 
They  quickly  increase  in  size  and  then  break  down,  forming  small  round 
ulcers  with  soft  edges,  showing  very  little  or  no  induration,  and  fairly 
definite  outlines;  the  base  is  covered  with  granulations.  It  is  usually 
(|uite  impossible  from  the  character  of  the  ulcers  alone  to  say  whether 
thev  are  tuberculous,  typhoid,  or  simple.  Later,  the  ulcers  fuse  into  one 
another  and  form  large  excavated  areas  extending  transversely  to  the 
long  axis  of  the  bowel.  On  the  peritoneal  surface  of  the  intestine 
opposite  an  ulcer  of  any  size  we  can  usually  find  a  number  of  minute 
grav  or  colorless  mihary  tubercles.  In  the  older  ulcers  the  edges 
become  indurated,  and  efforts  at  cicatrization  may  be  seen  in  a  con- 
tracted, puckered,  peritoneal  coat,  and  filling  in  of  the  ulceration  with 
granulations.  These  ulcers  rarely  perforate,  though  the  intestine  may  be 
.so  softened  that  when  taken  out  and  washed  it  may  appear  riddled  with 
holes.  The  peritoneum  usually  j^resents  a  more  or  less  general  adhesive 
peritonitis  and  may  be  more  or  less  thickly  sown  with  miliary  tubercles. 

The  lesions  of  the  mesenteric  nodes  may  be  an  apparently  simple 
hyperplasia,  or  there  may  be  miliary  tubercles,  or  tuberculous  nodules, 
or  diffuse  caseation  and  breaking  down,  so  that  the  nodes  are  full  of 
thick,  pale-greenisii  pus.  Wherever  there  are  tuberculous  ulcers  of  the 
intestine,  we  may  be  cjuite  sure  that  the  mesenteric  nodes  are  tuber- 
culous, even  though  on  section  they  appear  normal.  The  size  of  the 
individual  lymph  nodes  varies  from  1  to  3  cm.  They  may  be  grouped 
in  masses  of  considerable  size.  Holt  speaks  of  a  mass  the  size  of  a 
child's  head  at  birtii.  It  is  not  uncommon  to  see  masses  the  size  of 
a  hen's  egg  (Fig.  75). 

The  peritoneum  is  usually  matted  together  everywhere  and  full  of 


TUBERCULOSIS 


371 


Fig.  U 


Hypertrophy  of  Peyer's  patches  in 
the  small  intestine,  with  superficial 
erosions  resembling  ulcers. 


Tuberculous  ulcers  of  the  small  intestine.  The  lowest 
portion  shows  the  Peyer's  patch,  just  above  the  ileocecal 
valve,  a  favorite  seat  of  ulceration  of  any  kind. 


•A70 


INFECTK )  I  -S   1)1  SKA  SES 


miliary  tubercles.  It  iiuiy  contain  lar^c  tuberculous  masses,  or  there 
may  be  an  exudation  of  serum  into  the  peritoneum,  or  any  of  the  con- 
ditions described  under  Tuberculous  IVritonitis. 

Symptomatology. — These  are  altogether  indefinite-  in  the  great  majority 
of  eases.  It  is  not  unusual  to  find  extensive  ulceration  of  the  intestine 
in  tul)erculous  eases  in  which  there  have  been  no  intestinal  symptoms, 
and,  on  the  other  hand,  patients  in  the  last  stages  of  tuberculosis  may 
have  severe  (harrhea  without  tulxM-culous  le^sions  of  the  gut.  In  other 
eases  there  may  l)e  the  symptoms  of  a  chronic  ileocolitis  and  the  passage 
of  stools  containing  nuicus  and  blood.  The  latter  is  not  at  all  regular 
or  fre(|uent,  and  tlie  bleeding  is  more  excessive.     With  involvement  of 

Fig. 75 


A  mass  of  tuberculous  lymph  nodes ;  the  mass  laid  open  by  a  mesial  section.    These  nodes  lay  just 
at  the  ileocolic  junction,  and  are  the  ones  most  olten  afl'ected. 


the  luesenteric  lyni])h  nodes  and  the  peritoneum  the  abdomen  is 
distended  and  generally  tender  and  tympanitic.  In  some  instances 
the  enlarged  nodes  can  be  seen  and  felt  through  the  thin  abdominal 
walls.  With  either  local  or  general  tuberculosis,  the  temperature  reg- 
ularly shows  more  or  less  elevation.  The  course  of  the  disease  may  be 
very  rapid  or  very  slow.  Where  the  intestines  and  mesenteric  nodes 
alone  are  involved  the  course  is  slow,  like  that  of  chronic  ileocolitis  it 
may  be  ])rotracted  for  months.     It  is  always  fatal. 

Diagnosis. — W'ith  a  chronic  diarrhea  attended  by  fever,  distention  of 
the  abdomen,  and  the  presence  of  masses  of  enlarged  Ivmph  nodes  the 
diagnosis  may  be  easy.     Likewise,  in  cases  where  similar  conditions 


TUBERCULOSIS  373 

develop  in  a  child  already  suffering  from  tuberculosis.  In  the  primary 
cases  resembling  chronic  ileocolitis  the  differentiation  has  been  given 
under  the  latter  subject  (p.  266).  In  any  case  the  only  satisfactory 
proof  of  the  nature  of  the  lesion  is  the  finding  of  tubercle  bacilli  in  the 
mucus  of  the  feces.  For  evident  reasons  this  may  not  be  easy;  repeated 
examinations  may  be  required. 

Prognosis. — The  disease  is  fatal  sooner  or  later,  death  being  caused, 
as  a  rule,  by  exhaustion;  perforation  and  hemorrhage  have  been  the 
immediate  causes  of  death  in  some  cases. 

Treatment. — This  must  be  on  the  lines  of  an  ileocolitis.  Medicines 
are  of  little  value.  When  once  we  have  satisfied  ourselves  as  to  the 
diagnosis  the  prospect  of  recovery  being  practically  out  of  the  question, 
we  had  best  aim  to  make  the  patients  comfortable. 


TUBERCULOUS  PERITONITIS. 

Etiology. — In  tuberculosis  of  any  part  of  the  body,  the  intestines, 
lungs,  lymph  nodes  or  bones,  or  genital  organs,  it  is  possible  that  the 
peritoneum  may  be  involved.  Thus  in  125  cases  of  general  tuberculosis, 
in  nearly  all  of  which  the  lungs  were  the  chief  seat  of  disease,  I  found 
the  peritoneum  involved  in  9-  —i.  e.,  7  per  cent.  In  883  cases  of  tuber- 
culosis Biedert  found  peritoneal  lesions  in  18  per  cent.  These  figures 
are  from  the  results  of  postmortem  examinations  and  represent  the 
frequency  with  which  peritoneal  lesions  may  be  found  in  children 
suffering  from  tuberculosis  of  other  parts.  The  majority  of  these  cases 
would  not  be  recognized  as  cases  of  tuberculous  peritonitis  during  life. 
The  frequency  of  clinical  peritoneal  tuberculosis  is  quite  another  matter. 
This  varies  greatly  in  different  localities  or  countries,  for  reasons  which 
are  not  clear.  There  can  be  no  question  that  tuberculous  peritonitis 
is  much  more  common  in  Great  Britain  than  in  America. 

In  a  single  day  in  the  Hospital  for  Sick  Children,  Edinburgh,  I  saw 
more  cases  of  peritoneal  tuberculosis  in  young  children  than  I  had  seen 
in  ten  years  in  hospital  work  in  New  York  City.  In  America  it  is  cer- 
tainly a  very  rare  affection,  almost  never  seen  in  infants,  and  very 
rarely  in  children  under  the  age  of  seven  years. 

Peritoneal  tuberculosis  is  practically  always  secondary.  The  infection 
may  be  carried  by  the  blood  stream  or  by  the  lymphatics.  In  the  first 
class  the  peritonitis  is  simply  part  of  a  general  miliary  tuberculosis.  In 
the  second  class  the  infection  travels  from  some  of  the  neighboring 
organs,  intestine,  lungs,  spinal  column,  genital  organs,  usually  by  way 
of  the  lymph  nodes.  The  primary  factor  in  any  case  of  tuberculous 
peritonitis  is  therefore  the  original  infection.  In  some  instances  blows 
or  falls  on  the  abdomen  seem  to  have  excited  the  peritoneal  disease. 

Morbid  Anatomy  and  Symptomatology. — The  lesions  of  tuberculous 
peritonitis  are  varied,  and  as  the  symptoms  of  the  diseases  vary  with 
the  form  of  lesion  it  is  best  to  consider  them  together. 

1.  Miliary  Tuberculosis  of  the  Peritoneum. — This  is  the  form  of 
tuberculosis  of  the  peritoneum  regularly  met  with  in  cases  of  general 


374  INFECTIOUS  DISEASES 

tuberculosis.  The  miliary  tubercles  are  few  or  many;  usually  there  are 
great  numbers.  There  are  generally  lirni  adhesions  between  the  peri- 
toneal coatings  of  the  intestines,  and  between  the  intestines,  the  abdomi- 
nal wall,  and  the  viscera,  so  that  the  peritoneal  cavity  is  practically 
obliterated.  The  condition  gives  rise  to  no  distinctive  symptoms  and 
is  recognized  only  at  the  autopsy. 

2.  Miliary  I'ubercidosis  of  the  Peritoneum  with  Ascites. — In  this  case 
there  is  an  acute  eruption  of  miliary  tubercles  with  more  or  less  of  the 
manifestations  of  an  acute  peritonitis.  The  peritoneum  is  congested, 
cloudy,  and  may  be  coated  with  lymph.  There  are  adhesions  between 
the  intestinal  coils.  There  is  an  abundant  ert'usion  of  serum,  regularly 
clear,  but  it  may  be  seropurulent  or  even  bloody.  Tuberculous  lesions- 
are  constantly  found  in  other  parts  of  the  body. 

The  symptoms  in  this  form  of  peritoneal  tuberculosis  vary  greatly. 
In  some  cases  the  disease  begins  so  acutely  as  to  suggest  acute  entero- 
colitis, or  intestinal  obstruction.  There  are  fever,  vomiting,  abdominal 
pain  and  distention  with  fluid,  and  diarrhea  or  constipation.  In  other 
cases  the  onset  is  very  gradual  and  insidious  and  the  distention  of  the 
abdomen  with  fluid  is  the  first  symptom  to  attract  attention.  When 
the  disease  is  well  established,  there  is  regularly  some  fever,  although  it 
may  be  slight.  The  digestion  is  disturbed.  There  may  be  occasional 
vomiting,  and  the  bowels  are  constipated  or  loose.  The  abdomen  is 
then  markedly  distended,  the  skin  seems  thin  and  pale,  the  superficial 
veins  are  enlarged,  an<l  there  are  the  characteristic  physical  signs  of 
ascites.  In  some  instances  the  fluid  is  encapsulated  either  in  the  pelvis 
or  flank,  and  may  suggest  an  ovarian  cyst.  When  the  fluid  is  removed 
from  the  abdomen  it  may  be  possible  to  feel  some  nodules  in  the  peri- 
toneum or  enlarged  mesenteric  nodes;  often,  however,  this  is  impossible. 
The  fluid  reaccumulates  rapidly  after  tapping.  I'he  prospect  of  recovery 
is  usually  in  keeping  witli  the  onset;  the  acute,  severe  cases  do  badly; 
those  in  which  the  onset  is  slow  and  insidious  and  the  course  protracted 
usually  do  well. 

3.  The  Caseoiis  or  Ulcerative  Form. — In  this  case  there  are  extensive 
tuberculous  deposits  in  the  peritoneum  which  go  on  to  caseation.  There 
is  usually  an  abundant  effusion  of  fibrin  by  which  the  coils  of  intestine 
are  matted  together  and  to  the  various  viscera  (Figs.  76  and  77).  By 
these  adhesions  pockets  are  formed  which  may  be  filled  with  clear 
serum  or  thick,  tuberculous  pus  or  a  brownish  fluid.  The  tuberculous 
nodules  occur  in  any  part  of  the  peritoneum  and  in  the  abdominal  walls; 
the  process  may  lead  to  suppuration  and  the  formation  of  fistulse,  most 
often  in  the  neighborhood  of  the  umbilicus.  Arlvanced  tuberculous 
lesions  are  found  in  the  other  viscera,  especially  the  lungs. 

The  constitutional  symptoms  in  this  condition  are  usually  those  of 
a  general  tuberculosis,  with  considerable  fever;  it  may  be  of  the  hectic 
type:  rapid  pulse,  rapid  respiration,  sweating,  and  marked  prostration. 
The  abdominal  symptoms  consist  of  indigestion,  possibly  with  vomiting, 
more  or  less  colicky  pain  in  the  abdomen,  and  constipation  or  diarrhea. 
If  there  are  tuberculous  ulcers  in  the  intestine,  there  will  occasionally 


TUBERCULOSIS 


375 


be  blood  in  the  stools.  The  abdomen  is  distended,  tense;  nodules  may 
occasionally  be  seen  beneath  the  skin.  Unless  the  effusion  into  the 
peritoneum  is  very  large  the  signs  are  not  those  of  ascites,  but  of  scattered 
areas  of  dulness  from  encysted  fluid,  with  intervening  areas  of  tympany. 


Fig.  76 


Intestines  removed  en  masse  from  a  case  of  tuberculous  peritonitis.    Note  the  thickened  omentum 
containing  tuberculous  nodules  and  the  matting  together  of  the  intestines. 


Often  the  abdomen  has  a  rather  characteristic  doughy  feel  and  nodules 
may  be  detected  here  and  there  in  it.  In  some  instances  there  are 
fistulse,  especially  near  the  umbilicus,  discharging  characteristic  tuber- 
culous pus.  In  other  cases  the  fistulae  may  open  into  the  bowel.  The 
course  of  the  disease  in  this  form  is  steadily  progressive,  the  patients 


376 


INFECT  10 1 'S  DISEA  SES 


suffering  not  alone  from  the  peritoneal  hut  from  the  general  tuberculous 
lesions.  The  duration  is  usually  two  or  three  months.  The  patients 
die  of  exhaustion,  or  from  new  complications,  such  as  tuberculous  menin- 
gitis, rarely  from  the  peritoneal  process  itself. 

4.   FihroH.s  Form. — In  a  considerable  j)r()portion  of  all  the  cases  of 
tuberculous  peritonitis  there  is  no  effusion  of  serum  or  pus,  but  the 


Fig.  77 


A  mass  of  intestines  from  a  case  of  tuberculous  peritonitis  viewed  from  behind.    Matting  of  all  the 
tissues  and  the  masses  of  mesenteric  lymph  nodes. 


tubercles  are  surrounded  by  more  or  less  lymph  and  there  is  a  tendency 
to  cicatrization.  In  these  cases  the  peritoneum  is  greatly  thickened, 
dense  and  firm  and  full  of  miliary  tubercles,  the  tubercles  being  cpvered 
with  fibrous  tissue.  The  intestines  are  densely  matted  together,  the 
peritoneal  coating  of  liver  and  spleen  are  greatly  thickened  and  adherent 
to  adjacent  parts,  and  the  peritoneal  cavity  almo-st  completely  obliter- 
ated.    The  process  is  usually  general,  but  may  be  localized.     In  some 


TUBERCULOSIS  377 

instances  the  omentum  is  particularly  affected  and  is  converted  into  a 
ridge-like  tumor  lying  across  the  upper  abdomen.  In  other  instances 
this  condition  is  found  in  a  hernial  sac,  or  about  the  appendLx.  It  is 
not  infrequently  encountered  in  laparotomies  for  other  conditions. 

The  symptoms  of  the  fibrous  form  are  very  obscure.  It  may  remain 
entirely  latent,  to  be  discovered  only  at  autopsy.  Generally  the  onset 
is  ver\'  o-radual  and  insidious.  There  mav  be  a  definite  fever,  but  the 
temperature  is  often  normal  or  subnormal.  There  may  be  some  colicky 
pains  in  the  abdomen,  but  these  are  slight.  The  bowels  may.be  consti- 
pated or  loose.  The  abdomen  is  usually  distended  at  first  from  tjmapan- 
ites,  later  from  the  peritoneal  changes.  Sometimes  there  is  ascites, 
but  this  is  scant.  On  examination  it  may  be  quite  impossible  to  demon- 
strate any  abnormal  conditioiis  about  the  abdomen ;  usually  the  abdomen 
is  distended  and  tympanitic  over  the  greater  part.  There  may  be 
localized  areas  of  dulness,  or  there  may  be  masses,  such  as  the  rolled-up 
omentum,  which  can  be  felt. 

Symptoms  may  be  produced  by  the  contraction  of  the  adhesions. 
Frequent  vomiting  may  be  caused  by  traction  on  the  stomach,  or 
intestinal  obstruction  from  stricture  of  the  intestine,  or  there  may  be 
edema  from  pressure  on  the  vena  porta  or  vena  cava,  or  albuminuria 
from  involvement  of  the  renal  veins. 

The  course  of  the  disease  varies  greatly.  Spontaneous  recovery 
may  occur.  The  presence  of  tuberculous  lesions  in  other  parts  of  the 
body  has  much  to  do  in  determining  the  final  outcome.  The  duration 
of  the  disease  varies  from  a  few  months  to  several  years. 

Diagnosis. — In  certain  cases  of  miliary  tuberculosis  of  the  peritoneum 
and  also  of  the  fibrous  variety,  the  diagnosis  is  made  only  at  autopsy 
or  operation.  In  the  cases  associated  with  marked  changes  in  the  peri- 
toneum and  ascites,  the  diagnosis  lies  between  cirrhosis  of  the  liver 
and  simple  chronic  peritonitis.  Cirrhosis  of  the  liver  is  in  childhood 
an  extremely  rare  affection,  much  less  frequent  than  peritoneal  tuber- 
culosis. After  tapping  in  cirrhosis  we  may  be  able  to  make  out  that 
the  liver  is  abnormally  hard  or  small,  and,  in  syphilitic  cases,  irregular. 
Jaundice  is  more  common  in  cirrhosis;  fever  belongs  to  tuberculosis. 
A  study  of  the  cytology  of  the  fluid  should  help  us.  In  tuberculosis 
there  should  be  marked  preponderance  of  the  mononuclear  leukoc}i:es; 
in  cirrhosis  we  find  chiefly  endothelial  cells.  The  centrifuged  sediment 
may  be  examined  for  bacilli,  btit  the  inocidation  of  a  small  quantity  of 
the  fluid  into  a  guinea-pig  or  rabbit  is  a  much  safer  test.  Several  weeks 
will,  however,  be  reqtiired  to  determine  the  C}uestion  by  the  latter 
method.  An  encysted  exudate  is  always  in  favor  of  tuberculosis,  likewise 
the  presence  of  a  fistula. 

The  distinction  from  simple  chronic  peritonitis  may  be  even  more 
difficidt.  This  affection  is  also  rarer  than  tuberculosis  of  the  peri- 
toneum. A  good  family  history,  absence  of  fever  and  emaciation  are 
in  favor  of  a  simple  inflammatory  process.  If  ascites  is  present,  the 
fluid  may  be  tested  as  suggested  above.  If  the  cases  are  operated  upon, 
a  microscopic  examination  of  the  fibrous   nodules  or  inocidation  of  the 


378  INFECTIOUS  DISEASES 

exudate  may  be  reciuiivd,  to  detcM-inine  the  diagnosis,  so  closely  do  the 
conditions  resemble  each  other. 

The  ulcerative  form  of  tuberculous  peritonitis  is  ejisily  distinguished 
bv  the  presence  of  tuberculous  lesions  elsewhere  and  l)y  the  marked 
changes  in  the  peritoneum,  the  fever,  and  wasting. 

llectal  examination  under  an  anesthetic  may  be  of  great  help  in  any 
doubtful  case  in  enabling  one  to  detect  local  collections  of  fluid,  masses 
of  enlarged  lymph  nodes,  etc.,  which  might  not  be  accessil)le  to  ordinary 
palpation. 

Prognosis. — The  ulcerative  form  of  tubercidous  peritonitis  is  regularly 
fatal,  although  recovery  has  been  known  to  follow  the  discharge  of  an 
abscess  at  the  navel.  In  the  other  varieties  the  prognosis  is  fairly  good, 
many  of  the  cases  recovering  on  rational  treatment,  and  many  being 
improved,  if  not  cured,  by  laparotomy. 

Treatment. — There  has  been  a  great  deal  of  discussion  in  recent  years 
as  to  the  best  treatment  for  tuberculous  peritonitis,  and  the  question  is 
not  yet  settled.    Treatment  may  be  classed  as  either  medical  or  surgical. 

Medical  Treatment. — Fresh  air,  quiet,  and  good  nursing  are  of  prime 
importance.  The  patients  are  kept  in  bed  as  long  as  there  are  active 
symptoms  of  disease.  The  diet  is  made  as  nutritious  as  possible. 
Unless  there  is  diarrhea  or  vomiting,  the  patients  may  be  given  solid 
food,  even  if  there  is  fever.  Meat,  eggs,  and  milk  should  constitute 
the  major  part  of  the  dietary.  If  there  is  vomiting  or  diarrhea  these 
must  be  treated  on  general  principles.  Constipation  should  be  treated 
by  enemata  rather  than  purgatives.  Flatulence  and  indigestion  must 
be  treated  by  regulation  of  the  diet  and  the  use  of  bismuth  or  salol. 
For  the  relief  of  pain  the  application  of  heat  by  the  hot-water  bottle 
or  turpentine  stupes  may  be  employed.  Occasional  painting  with  iodine 
may  also  be  effective.  The  ascites,  unless  excessive,  nuiy  be  let  alone. 
If  it  seems  necessary,  the  abdomen  may  be  tapped,  but  not  in  the  ordi- 
nary way.  By  reason  of  the  adhesion  of  the  viscera  there  is  too  great 
danger  of  wounding  the  intestine  if  a  sharp  trocar  is  plunged  in,  as  is 
usually  done.  An  incision  should  be  made  through  tlie  alxlominal  wall 
and  a  blunt  trocar  introduced.  If  this  measure  fails,  laparotomy  must 
be  resorted  to.  Tonics,  such  as  cod -liver  oil,  arsenic,  or  the  syrup 
of  the  iodide  of  iron,  are  to  be  given  when  the  condition  of  the  stomach 
permits.  In  any  case  abundance  of  fresh  air  and  attention  to  all  the 
details  of  hygiene  are  of  prime  importance. 

Surgical  Treatment. — This  consists  in  a  free  la])arotomy  with  drain- 
age of  the  peritoneal  cavity.  It  is  the  only  method  advisable  for  cases 
of  the  ulcerative  type  or  for  any  case  in  which  the  effusion  is  excessive, 
particularly  if  the  effusion  be  purulent.  It  is  advocated  by  some  surgeons 
for  all  cases.  The  results  of  surgical  treatment  have,  for  the  most  part, 
been  very  gratifying.  Rotch,  of  Boston,  has  reported  G2  cases  of  tuber- 
culous peritonitis  observed  by  him,  32  of  which  were  operated  upon, 
with  12  deaths;  of  the  30  cases  not  operated  upon,  20  died.  Aldibert 
reports  52  operative  cases.  One  of  the  acute  miliary  type  died  after 
operation.       Of  6  cases  of  sul)acute  tyjx>  with  ascites,  but  one  died,  83 


TUBERCULOSIS  379 

per  cent,  recovering.  Of  16  cases  of  chronic  type  with  ascites,  but 
one  died,  93.8  per  cent,  recovering.  Of  9  cases  with  encysted  collec- 
tions of  fluid,  all  recovered.  Of  6  cases  of  the  fibroadhesive  type,  all 
recovered;  and  of  8  cases  with  suppuration,  7  recovered,  but  none  of 
the  cases  had  been  followed  more  than  a  year.  These  very  favorable 
figures  have  not  been  borne  out  by  later  reports,  but  the  results  have 
been  such  as  to  make  operation  advisable  in  any  case  not  yielding 
promptly  to  hygienic  and  palliative  treatment. 


TUBERCULOUS  MENINGITIS. 

By  d.  J.  McCarthy,  m.d. 

Tuberculous  meningitis  may  either  be  a  local  process  affecting  the 
meninges  secondary  to  a  tuberculous  focus  elsewhere,  or  it  may  be 
part  of  a  general  blood  infection  by  the  tubercle  bacillus. 

Etiology. — \^^lile  the  disease  may  occur  at  any  time  of  life,  it  is  much 
more  frequent  in  childhood.  It  is  rare  during  the  first  and  second 
years  of  life,  although  it  is  quite  possible  that  many  cases  of  basic 
meningitis  in  infancy  may  belong  to  this  affection.  The  largest  num- 
ber of  cases  occur  between  the  second  and  fifteenth  years  of  life.  Oper- 
ative procedures  on  tuberculous  lymph  nodes,  adenoid  growths,  and 
especially  on  tuberculous  joints,  may  determine  a  blood  infection  in 
which  the  brain  and  spinal  cord  are  most  intensely  affected  and  domi- 
nate the  clinical  picture.  In  those  cases  in  which  the  inflammation  is 
a  local  process  (not  a  manifestation  of  a  blood  infection)  it  is  usually 
secondary  to  a  tuberculous  focus  in  the  immediate  neighborhood  of 
the  meninges,  such  as  in  the  bones  of  the  skull  or  of  the  spine,  the 
cavities  of  the  face,  nasal  fossae,  the  orbit,  or  the  ear.  From  these 
areas  the  infection  may  be  direct  by  extension,  but  more  frequently  by 
lymphatic  transmission.  The  source  of  infection,  however,  in  the 
vast  majority  of  cases  must  be  sought  for  at  some  distant  point,  and 
is  usually  found  in  a  local  process  in  the  lungs  or  the  peribronchial 
lymph  nodes.  The  affection  may  originate  in  tuberculosis  of  the  abdom- 
inal organs,  the  joints,  the  bones,  superficial  lymph  nodes,  and  even 
the  skin.  Wliile  the  transmission  in  these  cases  is  probably  through 
the  blood  and  the  localization  of  the  process  in  the  meninges  is  due 
to  the  lessened  resistance  of  these  membranes  to  infection  and  the 
greater  resistance  of  the  other  tissues  of  the  body,  it  is,  however,  quite 
possible  that  lymphatic  transmission  may  be  of  much  more  importance 
than  has  heretofore  been  suspected. 

In  that  small  group  of  cases  in  which  a  careful  search  at  autopsy  does 
not  reveal  tuberculosis  elsewhere  in  the  body  the  source  of  infection 
may  be  direct  from  the  nasal  cavities.  The  relation  of  adenoid  growths 
in  the  nasal  pharynx  to  affection  of  the  meninges  should  be  borne  in 
mind.  George  B.  Wood  has  recently  called  attention  to  the  frequency 
of  affections  of  the  tonsils  and  adenoids  caused  by  the  tubercle  bacillus. 


380  INFECTIOUS  DISEASES 

Pathology. — Tlie  gross  appearance  of  tlie  brain  of  patients  dying 
from  tuberculous  meningitis  varies  greatly.  In  older  children  and  in 
adults  there  may  be  little  evidence  of  a  marked  inflammatory  process. 
Numerous  small  grayish  granules  are  found  on  the  outer  surface 
of  the  bloodvessels  and  may  be  found  only  after  careful  searching. 
The  \)\a  may  l)e  apparently  normal,  slightly  reddened  at  the  seat  of 
some  of  the  small  grayish  granules.  In  infancy  and  early  childhood 
the  inflammatory  process  Ls  much  more  distinct  and  intense  than  in 
adults.  The  inflammatory  exudate  at  times  has  a  semipurulent  appear- 
ance, is  j)resent  over  the  entire  base  of  the  brain,  and  extends  along  the 
bloodvessels  toward  the  convexity  or  into  the  brain  substance,  with  the 
production  of  local  areas  of  in.flammation  sometimes  of  a  hemorrhagic 
type.  I  have  seen  this  exudate  over  an  eighth  of  an  inch  in  thickness 
around  the  optic  commissure.  The  tubercle  bacillus  may  be  found 
in  the  granules,  in  the  exudate,  and  the  inflammatory  areas  in  the 
brain  substance.  The  examination  of  the  insides  of  the  bloodvessels 
may  show  an  intimal  tuberculosis  (Ilektoen). 

Distention  of  the  ventricles  due  to  an  internal  hydrocephalus  is 
present  even  in  those  cases  in  which  there  is  an  absence  of  exudate 
blocking  up  the  communication  of  the  ventricles  with  the  subarachnoid 
spaces.  This  Is  probably  due  to  a  toxic  irritation  or  actual  inflamma- 
tion of  the  ependymal  lining  of  the  ventricles.  The  brain  substance 
is  edematous  and  there  Is  evidence  in  the  flattened  convolutions  of 
intense  intracranial  pressure.  In  a  small  number  of  cases  the  spinal 
meninges  may  also  be  infected  by  the  inflammatory  process.  While 
the  process  Is  usually  confined  to  the  cervical  region,  the  entire  cord  is 
at  times  aftected. 

Ss^nptomatology. — The  s\Tnptomatology  is  so  complex,  varying  with 
the  intensity  of  the  inflammatory  process,  the  presence  or  absence  of 
exudate,  and  the  complicating  cerebral  intoxication  that  we  shall  divide 
the  course  of  the  disease  into  three  stages — the  stage  of  invasion,  the 
stage  of  irritation,  the  stage  of  coma  and  paralysis. 

Stage  of  Invasion. — For  a  varying  length  of  time  (one  to  several 
weeks)  the  child  loses  weight,  is  peevish,  irritable,  restless  at  night, 
grinds  the  teeth,  has  no  desire  to  play,  and  is  drowsy  in  the  daytime. 
A  slight  temperature  develops  slowly,  but  usuall}  does  not  rise  above 
100°  or  at  the  most  101°  F.  at  night.  The  bowels  become  constipated 
although  in  a  small  number  of  cases  there  may  be  diarrhea.  Head- 
aches now  develop  and  may  be  associated  with  vomiting.  Headache 
may  be  present  from  the  beginning  of  tlie  prodromal  period.  The 
presence  of  headache,  constipation,  irritability,  and  vomiting  in  a  child 
exposed  to  a  tuberculous  infection  should  put  the  physician  on  his  guard 
for  an  oncoming  meningitis. 

Stage  of  Inflammatory  Irritation. — As  the  inflammatory  process 
becomes  marked  the  fever  increases  somewhat,  the  child  is  evidently 
much  weaker  and  very  sick,  and  complains  of  light  and  sounds.  The 
irritability  is  increased;  the  child  lies  in  a  semisomnolent  condition, 
answering  when   spoken   to   in   a   peevish   manner.     Constipation   is 


TUBERCULOSIS  381 

marked;  the  pulse  is  slow  and  irritable.  If  the  child  is  excited  or  dis- 
turbed by  moving,  the  pulse  will  ascend  from  60,  70,  or  80  up  to  140. 
The  pulse  may,  however,  be  very  variable.  Other  vasomotor  phenom- 
ena are  marked,  such  as  alternate  flushing  and  paling  of  the  cheek  and 
of  the  trunk.  At  times  brilliant-red  patches  of  irregular  outline  develop 
and  last  for  several  hours  on  one  portion  of  the  body  and  then  disap- 
pear, reappearing  later  in  other  areas.  In  the  later  stages  of  the  dis- 
ease a  distinct  marbling  of  the  skin  may  appear.  The  headache  is 
more  intense  and  the  irritability  is  increased  by  a  hypersensitiveness  to 
touch  of  the  entire  body.  Motor  phenomena  are  usually  very  marked. 
Rigidity  of  the  muscles  of  the  neck  and  of  the  back,  retraction  of  the 
head,  grinding  of  the  jaws,  pulling  up  of  the  angles  of  the  mouth,  and 
strabismus  are  present.  The  rigidity  may  be  so  marked  that  the  body 
may  be  lifted  as  one  piece  by  elevating  pressure  on  the  occiput.  The 
limbs  may  become  rigid  and  contracted  with  increase  of  the  reflexes. 
General  convulsions  may  occur  or  may  be  absent  throughout  the  entire 
course  of  the  disease.  Even  in  such  cases  there  are  twitchings  and 
jerkings  of  the  extremities.  Partial  convulsions  may  occur.  At  this 
stage  Kernig's  symptom  is  well  developed.  The  child  after  several 
days  becomes  stuporous  and  may  at  times  mutter  to  itself,  but  dis- 
tinct delirium  is  comparatively  rare.  Variations  in  the  respiratory 
rhythm  are  present  throughout  the  entire  stage  and  are  almost  charac- 
teristic. Even  when  the  child  is  quiet  there  is  a  distinct  irregularity 
of  the  rhythm,  with  inequality  of  the  amplitude  of  the  respiratory  excur- 
sions, "a  disharmony  of  association  between  the  movements  of  the 
diaphragm  and  those  of  the  thoracic  walls."  As  the  disease  advances 
respirations  become  more  irregular,  a  period  of  suspension  of  the  respi- 
ratory movements  being  followed  by  long,  deep,  sighing  respirations. 
Toward  the  end  the  respirations  may  follow  the  Cheyne-Stokes  type. 

The  pupils  early  in  this  stage  may  be  contracted,  but  later  become 
dilated  and  at  times  may  be  unequal.  The  irritation  of  the  occulo- 
motor  nerves  at  first  produces  a  spasmodic  internal  strasbismus  fol- 
lowed by  a  paralytic  squint.  Slow  movements  of  the  eyes  from  one 
side  to  the  other  and  even  distinct  nystagmus  may  be  observed.  The 
ophthalmoscope  reveals  in  the  majority  of  cases  a  moderate  choking 
of  the  disk  and  in  a  smaller  number  of  cases  bright,  shining  spots  on 
the  choroid  (miliary  tubercles  of  the  choroid),  which  when  seen  are 
absoutely  diagnostic. 

Stage  of  Coma  and  Paralysis. — ^The  child  is  now  unconscious;  the 
spasm  of  the  neck,  of  the  back,  and  of  the  extremities  relaxes ;  the  pupils 
are  markedly  dilated,  the  eyeballs  turned  outward  and  upward,  the 
lids  are  half-closed,  and  complete  blindness  is  present.  The  pulse  is 
very  rapid,  the  respiratory  rhythm  is  irregular,  the  superficial  tempera- 
ture is  subnormal,  the  rectal  temperature  usually  high,  although  it 
may  be  subnormal.  Convulsions  may  occur,  but  are,  as  a  rule,  very 
light  and  limited  as  to  time  and  distribution.  They  may,  however,  be 
as  intense  at  the  end  as  at  the  beginning  of  the  second  stage,  and  may 
be  followed  by  a  temporary  paralysis.     The  paralysis  of  this  stage  is, 


382  INFECTIOUS  DISEASES 

however,  usually  permanent,  due  to  destruetion  of  the  nerve  tissues. 
The  extremities  are  flaccid  and  relaxed,  there  is  compl(>te  paralysis  of 
the  eye  muscles,  a  dropping  of  the  angles  of  the  mouth  with  loss  of 
expression,  and  a  paralytic  condition  of  the  jaw.  Sometimes  retention 
of  urine  occurs  toward  the  end  of  this  stage.  As  the  end  ap])roaches 
cyanosis  and  lividity  of  the  skin  and  mucous  membranes  appear,  the 
extremities  and  trunk  become  cold,  and  death  slowly  takes  place.  Death 
sometimes  follows  a  general  convulsion. 

The  course  of  the  disease  varies  with  the  intensity  of  the  infection 
and  of  the  inflammatory  process  and  the  age  of  the  child.  In  infants 
a  fatal  termination  may  be  expected  within  a  week.  Death  may  occur 
in  children  under  two  years  of  age  in  two  or  three  days  from  involve- 
ment of  the  base  and  convexity.  The  onset  is  sudden,  with  headache, 
high  fever,  convulsions,  and  a  rapid  fatal  termination  before  coma 
appears.  In  later  childhood  the  disease  runs  a  course  of  from  one  to 
two  weeks.  There  are  other  cases  running  a  subacute  course  and  last- 
ing from  four  to  six  weelcs. 

Diagnosis. — The  diagnosis  of  tuberculous  meningitis  from  other 
forms  of  meningitis  depends  on  the  discovery  of  some  active  or  latent 
focus  of  tuberculosis  elsewhere  in  the  body  and  the  presence  of  tubercle 
bacilli  in  the  cerebrospinal  fluid.  While  the  clinical  picture  in  some 
cases  is  typical  it  often  does  not  differ  essentially  from  that  presented 
in  other  forms  of  meningitis.  A  prolonged  prodromal  period  with  con- 
stipation, bradycardia,  slight  elevation  of  temperature,  with  the  pul- 
monary and  ocular  symptoms  above  described  will  differentiate  the 
tuberculous  from  other  forms  of  meningitis.  '^Die  non-tuberculous 
forms  of  meningitis  may  be  distinguished  by  the  suddenness  of  onset, 
the  absence  of  prodromes,  the  initial  fever,  and  the  rapidity  of  course. 
When  the  meningeal  infection  is  a  part  of  a  general  miliary  tubercu- 
losis affecting  other  organs  a  typhoid  state  may  be  presented,  leaf  ling 
to  a  diagnosis  of  typhoid  fever  with  symptoms  of  meningeal  irritation. 
The  absence  of  leukocytosis  and  the  presence  of  the  Widal  reaction 
in  the  blood  and  the  absence  of  tubercle  bacilli  in  the  cerebrospinal 
fluid  should  (>asily  diil'erentiate  the  two  conditions. 

From  brain  tumor  in  children  the  diagnosis  is  made  by  the  slow 
onset  of  the  symptoms  in  tumors  with  the  absence  of  fever,  the  greater 
i;, tensity  of  th(^  optic  neuritis,  and  the  presence  of  localizing  symptoms. 

Lumbar  Puncture. — The  examination  of  the  cerebrospinal  fluid  as 
a  method  of  diagnosis,  in  tuberculous  as  in  other  forms  of  meningitis, 
is  of  great  value.  Puncture  with  a  large  hypodermic  needle  or  small 
antitoxin  syringe  may  be  made  below  the  termination  of  the  spinal 
cord  at  the  second  lumbar  vertebra  without  injury.  I^cal  anesthesia 
may  be  used  and  it  is  sometimes  advisable  to  produce  slight  chloro- 
form anesthesia.  This  is,  however,  in  the  great  majority  of  cases 
unnecessary.  Thorough  cleanliness  both  as  to  instruments  and  the 
skin  is  essential  to  prevent  infection  of  the  spinal  meninges.  The  point 
of  the  necflle  should  be  inserted  between  the  spinous  processes  a  little 
to  one  side  of  the  median  line.     At  a  varying  distance  depending  on 


TUBERCULOSIS  333 

the  age  of  the  child  {2\  cm.  in  infants)  and  the  interspace  selected, 
the  needle  will  penetrate  the  spinal  canal.  The  fluid  runs  drop  by 
drop  and  something  may  be  learned  from  its  character.  In  tuber- 
culous meningitis  it  is  usually  clear,  and  is  as  opalescent  as  the 
normal  fluid ;  it  may  show  a  sediment  on  standing,  or  it  may  be  turbid. 
In  simple  meningitis  it  may  be  clear.  In  purulent  meningitis  it  is 
cloudy  or  distinctly  pussy.  Cover-slip  preparations  should  be  made 
and  carefully  studied  both  for  the  organisms  and  also  for  the  char- 
acter of  the  formed  cellular  elements.  The  technique  for  the  exami- 
nation of  the  fluid  for  the  presence  of  tubercle  bacilli  is  given  bv  Hand^ 
as  follows:  The  fluid  should  be  allowed  to  drop  from  the  needle 
into  a  sterile  test-tube,  which  is  then  stoppered  with  cotton  and  allowed 
to  stand  for  several  hours,  or  until  a  strand  of  fibrin  has  formed;  this 
occurs  in  from  one  to  six  hours,  and  it  either  settles  to  the  bottom  or 
reaches  from  the  top  of  the  fluid  down  to  the  bottom,  spreading  out 
in  a  fan-shaped,  delicate  film.  A  straight  platinum  needle,  not  a  loop, 
is  touched  to  one  edge  of  the  fibrin,  the  adhesion  being  very  firm;  the 
fibrin  is  then  transferred  to  a  slide,  care  being  taken  to  tip  the  test-tube 
so  that  the  fibrin  constantly  floats  in  liquid ;  a  few  drops  of  the  fluid  are 
to  be  poured  with  the  fibrin  on  to  the  slide,  for,  if  the  fibrin  emerges  for 
but  an  instant  from  the  fluid,  it  will  either  roll  up  into  a  cord  through 
which  nothing  can  be  seen  or  it  will  wrap  itself  so  tightly  around  the 
platinum  needle  that  it  cannot  be  detached;  to  prevent  this  the  edge  of 
the  test-tube  should  be  flanged  and  not  straight;  when  once  on  the 
slide  and  floating  in  the  fluid,  it  can  be  carefully  separated  from  the  tip 
of  the  platinum  needle  with  the  help  of  an  ordinary  needle  or  pin;  the 
excess  of  fluid  is  drained  ofl'  from  the  slide  and  the  remainder  is  evap- 
orated by  gentle  heat,  it  being  not  only  unnecessary  put  usually  fatal  to 
the  success  of  the  examination  to  press  the  fibrin  between  two  slides; 
the  film  is  fixed  by  heat,  stained  in  the  usual  manner  and  then  carefully 
gone  over  with  a  mechanical  stage.  A  point  for  the  protection  of  the 
examiner  is  worth  mentioning;  all  of  the  germs  are  not  caught  in  the 
fibrin,  but  some  float  free  in  the  fluid,  and  as  it  is  well  to  flood  the  slide 
even  to  the  risk  of  overflowing,  a  blotter  or  piece  of  filter-paper  placed 
beneath  the  slide  will  absorb  both  the  fluid  and  the  stray  germs,  and 
disinfection  is  then  easily  accomplished  by  combustion;  if  the  blotter 
is  dark  in  color,  the  film  of  fibrin  can  then  be  seen  much  more  easily 
and  located  on  the  slide.  The  next  step  in  the  examination  is  the  taking 
of  cultures.  After  the  chemical  examination,  for  which  5  c.c.  will 
suffice,  the  remainder  can  be  used  for  inoculation  into  guinea-pigs  if 
this  is  deemed  advisable;  this  is  hardly  necessary  if  tubercle  bacilli 
have  been  found,  but  it  is  very  desirable  in  all  other  cases  and  should 
be  carried  out,  if  possible,  for  then  the  exclusion  of  tuberculosis  rests  on 
unassailable  ground.  The  non-tuberculous  cases  do  not  show  the 
fibrin  formation  in  anything  like  the  degree  that  tuberculous  cases  do; 
in  the  former  there  usually  being  a  scanty,  yellowish-white  sediment 

1  Philadelphia  Medical  Journal,  Augusu  30, 1902. 


384  IXFKCTIOUS  DISEASES 

of  leukocytes  at  the  bottom  of  tlio  test-tube,  extending  for  a  short  dis- 
tance up  the  sides. 

If  this  teehnicjue  l)e  carefully  followed  tubercle  bacilli  will  be  foinid 
in  practically  100  per  cent,  of  cases  of  tuberculous  meningitis. 

The  chemical  examination  of  the  residual  fluid  may  be  made,  and 
while  it  o-ives  valuable  data,  is  not  as  imp(jrtant  as  the  microscopic  exami- 
nation. The  changes  to  be  expected  are  a  diminution  or  absence  of 
the  normal  sugar-reacting  substance  of  the  fluid,  an  increase  of  the 
albumin,  and  the  presence  of  leukocytes.  The  normal  (juantity  of 
copper-reducing  substance  in  the  fluid  (sugar?)  is  3  to  5  cgm.  in  100. 
The  normal  amount  of  alliumin  Is  0.25  part  in  1000.  A  study  of  the 
cell  elements  in  the  fluid  shows  a  variation  in  the  different  forms  of 
meningitis.  The  polynuclear  leukocytes  are  in  the  majority  in  the 
non-tuberculous  forms  of  meningitis,  the  lymphocytes  in  the  tubercu- 
lous form.  In  the  epidemic  form  the  diplococcus  intracellularis  will 
be  found  after  properly  staining  cover-slips  made  from  the  sediment 
of  the  centrifugated  fluid.  Staphylococci,  pneumococci,  and  other 
pyogenic  organisms  have  been  found  in  other  forms  of  meningitis. 

Prognosis. — Tuberculous  meningitis  may  be  considered  to  be  univer- 
sally fatal.  In  an  extensive  experience  in  the  examination  of  the  brains 
of  adults  and  children  dying  from  pulmonary  tuberculosis  at  the  Phila- 
delphia Hospital  and  the' Henry  Phipps  Institute  I  have  seen  cases  which 
presented  at  autopsy  evidence  of  healed  tuberculous  inflammatory 
lesions  of  the  meninges.  I  have,  however,  never  seen  a  case  of  tuber- 
culous meningitis  recover.  Ord  and  Waterhouse  report  a  case  of 
recovery  by  trephining  and  draining.  I  have  seen  only  one  case  treated 
in  this  manner  with  an  unfavorable  result.  Furbringer  reports  a  case 
of  recovery  after  spinal  puncture,  tubercle  bacilli  being  found  in  the 
cerebrospinal  fluid.  The  record  of  two  cured  cases  in  the  literature 
calls  attention  to  the  hopeless  nature  of  the  affection. 

Treatment. — The  treatment  is  entirely  symptomatic.  A  purgative  in 
the  early  stage  is  indicated ;  ice-bags  to  the  head  or  along  the  spine  to 
control  the  pain,  a  proper  nourishing  diet,  and  a  quiet,  darkened  room 
will  add  to  the  comfort  of  the  patient.  The  surgical  treatment  (opening 
the  skull  by  trephining,  and,  more  recently,  by  a  large  osteoplastic  flap) 
practised  by  Agnew  in  1891,  and  by  Ord  and  Waterhouse,  Jaboulay  and 
others  has  been  successful  only  on  the  one  case  above  referred  to,  but  in 
view  of  the  hopeless  nature  of  the  affection  it  is  deserving  of  more  extended 
practice.  The  theory  upon  which  this  treatment  is  based  is,  that  the 
exposure  of  the  meninges  to  the  air  should  have  the  same  beneficial 
effect  as  in  tuberculous  peritonitis,  and  should  also  relieve  the  increased 
intracranial  pressure.  The  use  of  lumbar  puncture  in  cases  where  the 
cerebrospinal  communication  is  open  produces  an  amelioration  of  the 
symptoms  without,  however,  any  permanent  results. 


CHAPTEE    XVI. 

DIPHTHERIA. 
By  MATTHIAS  NICOLL,  Jr.,  M.D. 

Diphtheria  (Greek,  J^fdipo.,  a  skin  or  membrane)  is  an  acute 
infectious  disease,  due  to  the  presence  and  growth  of  the  Klebs-Loeffler 
bacillus  on  a  mucous  membrane  or  wound  of  the  skin  surface,  upon 
which  it  produces  a  pseudomembrane.  General  symptoms  especially 
referable  to  the  nervous  system  are  caused  by  the  elaboration  of  certain 
toxins  chiefly  at  the  point  of  inoculation. 

The  pathological  changes  in  the  organs  are  caused  in  great  part  by 
toxemia,  but  also  by  the  presence  and  growth  of  the  Klebs-Loeffler 
bacillus  alone  or  in  combination  with  other  organisms  within  the  tissues. 

No  part  of  the  earth  seems  to  be  free  from  at  least  occasional  out- 
breaks of  the  disease.  In  large  cities  it  is  endemic,  the  cases  varying 
in  different  seasons  and  years,  in  number  and  average  degree  of  viru- 
lence. In  country  places  and  small  towns  it  occurs  as  a  local  epidemic, 
one  or  more  cases  being  brought  into  a  community  from  extraneous 
sources  and  spreading  the  disease. 

From  an  analysis  of  a  large  number  of  cases  in  this  country,  Conti- 
nental Europe  and  England,  one  may  conclude  that  the  disease  is  con- 
siderably less  frequent  during  the  warmer  months  of  the  year,  and 
this  is  readily  explained  by  the  fact  that  during  these  months  the  people 
live  more  out-of-doors,  the  children  leave  their  overheated  and  over- 
crowded houses  for  a  greater  part  of  the  day,  schools  are  closed,  and 
the  prevalence  of  catarrhal  affections  of  the  upper  air  passages  is 
greatly  diminished. 

Etiology.  Modes  of  Infection. — Nothwithstanding  the  impossibility  of 
tracing  the  source  of  many  apparently  isolated  and  puzzling  cases 
of  diphtheria,  it  may  be  stated  positively  that  one  case  of  the  disease 
always  arises  directly  or  indirectly  from  another.  The  most  frequent 
methods  of  infection  are  by  the  inspiration  of  air,  especially  in  closed 
rooms  infected  by  a  diphtheria  patient,  the  use  of  handkerchiefs  and 
towels  in  common,  from  handling  infected  toys,  books,  and  clothing,  and 
later  by  transferring  the  fingers  to  the  mouth,  the  use  of  infected  spoons, 
dishes,  and  food,  and  by  kissing  upon  the  mouth. 

Physicians  and  nurses  who  do  not  take  proper  precautions  in  dis- 
infecting their  persons  and  clothing  are  frequently  the  means  of  carrying 
contagion  from  infected  to  healthy  individuals. 

The  theory  of  indirect  infection  presupposes  what  we  know  to  be  a 
fact,  that  the  diphtheria  bacillus  may  live  for  weeks  and  months,  not 
25  (385) 


38G  INFECTIOUS  DISEASES 

oiilv  in  throats  which  have  every  appearance  of  health,  hnt  also  dried 
npon  (■lothin<,%  l)edding,  wall-paper,  carpets,  etc.,  which  have  not  been 
properly  disinfected.  An  unusual  but  well-authenticated  method  of 
transmission  is  by  means  of  a  milk  supply  contaminated  by  dairy 
helpers  who  arc  afflicted  with  the  disease.  INlilk  is  an  excellent  culture 
medium  for  the  Klebs-Loeffler  bacillus  and  thus  affords  a  ready  method 
of  conveying  actively  growing  colonies  to  consumers  of  the  infected 
supply. 

Transmission  of  diphtheria  by  domestic  animals  has  not  been  sub- 
stantiated, nor  its  conveyance  by  means  of  defective  drainage  and  sewer 
gas  proved.  Nevertheless,  unsanitary  conditions  of  drainage  tend  to 
j^rolong  the  presence  of  the  diphtheria  germ  when  once  implanted. 

Prcdisposimj  Factors. — No  race  can  be  said  to  be  immune  to  the 
disease.  According  to  some  observers,  negroes  show  a  greater  degree 
of  resistance  than  the  white  races.  By  some,  the  Jews  are  thought  to 
l)e  especially  susce})tible,  but  this  apparent  susceptibility  may  readily 
be  accounted  for  by  the  fact  that  the  poorer  Jewish  quarters  are  usually 
those  in  which  overcrowding  and  lack  of  sanitary  precautions  are  most 
in  evidence. 

Age  has  an  important  bearing  on  its  occurrence.  Children  under  one 
vear  of  age  and  especially  those  in  the  first  six  months  of  life  possess 
a  relative  inununity.  The  ages  from  three  to  five  years  may  be  set 
down  roughly  as  the  time  of  greatest  susceptibility;  from  the  ninth  to 
the  tenth  year  the  susceptibility  slowly  decreases,  and  from  this  period 
rapidly  decreases. 

The  disease  affects  both  sexes  in  about  equal  proportions.  As  with 
other  acute  infections,  diphtheria  attacks  by  preference  those  of  low 
vitality  and  especially  the  subjects  of  chronic  catarrhal  conditions  of 
the  uj)per  air  passages  and  hypertrophy  of  the  neighboring  lymphatic 
structures  (tonsils  and  adenoids). 

Bacteriology. — The  bacillus  described  by  Klebs  and  lyoeffler  in  1S83- 
1884  and  later  shown  by  Roux  and  Yersin  to  be  the  cause  of  diphtheria 
has  been  exhaustively  studied.  It  is  capable  of  exhibiting  quite  a  wide 
degree  of  structural  difference,  even  in  the  same  culture  medium, 
depending  on  the  length  of  time  a  culture  is  grown,  the  consistence  of 
the  medium,  temperature,  etc. 

Grown  on  Klebs-Loeffler  serum,  the  medium  most  generafly  used  for 
diagnostic  purposes,  for  twelve  hours  or  more  at  a  temperature  somewhat 
below  100°  F.,  and  stained  with  aJkaline  methyl-blue  solution,  the  bacilli 
are  seen  as  fine  rods,  straight  or  slightly  curved,  usually  noticeably 
clubbed  at  one  or  both  ends  and  arranged  in  larger  or  smaller  groups 
with  great  irregularity;  occasionally  end  to  end  in  a  broken  line,  but 
more  often  one  bacillus  forming  an  angle  with  another,  a  parallel 
arrangement  not  being  coiumoidy  obsei-ved.  The  length  varies  from 
1  to  6/i,  the  width  from  O.'A  to  0.8//. 

Conunon  variations  from  the  above  are  bacilli  pointed  at  one  or  both 
ends,  thick  at  one  end  and  pointed  at  the  other  (so-called  wedge  shaped). 
Thick  and  short  forms  arc  occasionally  met  with  resembling  so  closely 


DIPHTHERIA  3g7 

certain  of  the  pseudodiphtheria  bacilli  that  the  true  nature  of  the 
organism  can  only  be  positively  determined  by  clinical  symptoms, 
culture  methods,  and  animal  inoculation. 

Neisser's  stain  is  often  used  to  bring  out  certain  morphological  char- 
acteristics more  clearly  than  can  be  done  with  the  Klebs-Loeffler  stain. 
It  is  made  as  follows :  Solution  No.  1 :  1  c.c.  methyl  blue  dissolved  in  20  c.c. 
96  per  cent,  alcohol,  90  c.c.  distilled  water,  50  c.c.  glacial  acetic  acid. 
Solution  No.  2:  2  c.c.  vesuvin  to  1  litre  of  boiling  distilled  water.  Stain 
in  No.  1  for  three  to  ten  seconds,  stain,  wash  in  water,  and  stain  in  No.  2 
for  three  to  five  seconds.     Wash  off  and  examine. 

The  body  of  the  bacillus  will  thus  be  stained  a  brownish  color,  while 
the  so-called  polar  granules  of  Neisser-Ernst  will  be  seen  at  one  or  both 
ends  of  the  rod  as  dark -blue  oval  bodies,  the  diameters  of  which  are 
invariably  somewhat  greater  than  that  of  the  bacillus. 

The  chief  characteristics  of  the  Klebs-Ivoeffler  bacillus  may  be 
set  down  in  brief  as  follows:  It  is  non-motile,  and  while  growing 
more  luxuriantly  in  the  presence  of  oxygen,  thrives  also  without  it.  It 
does  not  form  spores,  but  will  live  when  dried  for  weeks  and  months, 
especially  when  protected  from  sunlight.  It  is  readily  killed  by  a 
temperature  of  136°  F.  It  is  not  killed  by  freezing  temperatures,  begin- 
ning to  grow  at  a  temperature  of  20°  C.  (68°  F.),  but  most  luxuriantly 
about  body  temperature  (96°  to  99°  F.). 

On  apparently  healthy  mucous  membrane  the  bacillus  may  exist  for 
months,  both  in  those  who  are  convalescing  from  the  disease  and  in 
the  throats  of  those  who  have  never  exhibited  any  symptoms  of  it,  but 
who  consciously  or  unconsciously  have  been  exposed  to  infection.  Such 
bacilli,  while  not  apparently  harmful  to  those  who  must  in  consequence 
be  regarded  as  possessing  a  natural  or  acquired  immunity,  are  never- 
theless sources  of  great  danger  when  transferred  to  susceptible  indi- 
viduals, and  it  is  probable  that  recurrent  attacks  of  the  disease  are  often 
due  to  the  presence  of  these  latent  germs,  which  take  on  active  growth, 
by  reason  of  a  discontinued  immunity,  from  temporary,  general,  or 
local  pathological  conditions. 

On  blood  serum  after  twelve  hours'  growth  the  colonies  of  Klebs- 
Loeffler  bacilli  are  seen  as  milky-white,  gray,  or  yellowish  points,  slightly 
elevated  with  irregular  borders.  Neighboring  colonies  may  coalesce. 
The  serum  is  not  liquefied. 

In  bouillon  (alkaline,  slightly  acid  or  neutral)  the  bacilli  grow  readily, 
producing  acid  in  their  growth.  Of  other  media,  milk  may  be  mentioned 
as  a  favorable  one,  its  appearance  not  changing  through  the  growth  of 
the  organism. 

According  to  Dr.  W.  H.  Park  the  bacillus  is  pathogenic  for  guinea- 
pigs,  rabbits,  chickens,  birds,  and  cats.  Moderately  so  for  dogs,  goats, 
cattle  and  horses,  and  not  for  rats  and  mice. 

Diphtheria  bacilli  differ  widely  in  their  virulence,  from  those  which 
produce  death  with  fearful  rapidity  to  those  which,  apparently  possessing 
all  the  cultural  and  morphological  characteristics  of  the  former,  are 
absolutely  non- virulent. 


388 


INFECTIOUS  DISEASES 


Between  these  two  classes  may  be  mentioned  a  type  of  bacilli  which 
when  inoculated  into  guinea-pigs  produces  a  chronic  disease,  slow  in 
its  course  and  ending  fatally  by  inducing  a  state  of  general  inani- 
tion. 

It  has  been  shown  tiiat  the  virulence  of  certain  avirulent  bacilli  may 
be  restored  to  them  by  passage  through  the  bodies  of  animals. 

The  characteristic  lesions  produced  by  inoculating  animals  with 
diphtheria  are  identical  with  those  found  at  autopsy  on  human  beings 
dead  of  the  disease. 

For  a  long  time  it  was  supposed  that  the  bacillus  of  diphtheria,  when 
implanted  upon  a  mucous  membrane,  showed  no  tendency  to  invade 
other  structures  save  those  in  direct  continuity  with  the  site  of  the 
lesion,  trachea,  lungs,  etc.  Careful  investigation  of  the  various  organs, 
however,  show  this  not  to  be  the  case,  but  that  the  bacillus  may 
be  carried  by  the  blood  and  lymph  stream  to  all  parts  of  the  body. 
It  is  found "  in  pure  cidture,  or  associated  with  other  organisms, 
notably,  streptococci,  pneumococci,  and  staphylococci.  This  association 
is  especially  seen  in  the  lungs.  In  the  other  organs,  liver,  spleen,  etc., 
the  bacilli  may  be  found  alone. 

How  great  a  part  this  migratory  bacillus  takes  in  producing  the 
symptom-complex  of  the  disease,  as  well  as  the  local  lesion  foimd  in  the 
organs,  cannot  be  definitely  determined.  As  a  rule,  the  migration  is 
seen  in  severe  and  especially  in  septic  cases,  although  not  confined  to  the 
latter.  It  is  reasonable  to  suppose  that  wherever  in  the  body  living 
virulent  diphtheria  bacilli  are  found,  that  they  perform  their  share  in 
producing  the  toxemia  peculiar  to  the  disease. 

In  the  lungs,  the  accessory  sinuses  of  the  nose,  and  middle  ear,  the 
association  with  other  organisms  produces  marked  pathological  changes. 

The  most  frecjueiit  and  dreaded  complication  of  the  disease,  broncho- 
pneumonia, is  due  not  only  to  the  action  of  the  toxins  on  the  pulmonary 
structure,  but  to  the  actual  presence  of  the  bacillus  within  them,  always 
associated  with  other  organisms. 

The  question  as  to  the  relation  between  certain  diphtheria-like  bacilli 
(pseudodiphtheria  bacilli)  and  the  bacillus  of  Klebs-Loeffler  cannot 
here  be  entered  into  at  length.  Sufficient  to  say  that  a  minority  of 
observers  regard  the  former  as  but  varieties  of  the  true  organisms  and 
capable  under  certain  conditions  of  assuming  all  the  characteristics  of 
the  latter.  The  majority  hold  the  opposite  opinion — namely,  that  the 
Klebs-Loeffler  bacillus,  while  it  may  be  absolutely  avirulent  and  lacking 
in  certain  cultural  and  morphological  characteristics,  belongs  to  a 
distinct  class,  and  under  no  circumstances  whatever  can  the  pseudo- 
organism  be  made  to  possess  all  the  characteristics  of  the  Klebs-Loeffler 
bacillus. 

It  is  at  times  very  difficult,  even  impossible,  to  state  positively  that 
such  and  such  an  organism  belongs  to  the  class  of  Klebs-Loeffler  bacilli, 
judging  from  a  morphological  standpoint,  especially  in  the  absence  of 
clinical  data.  Fortunately  this  is  not  a  very  common  occurrence,  and 
repeated  cultures  will  generally  serve  to  settle  the  question  of  diagnosis. 


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DIPHTHERIA 


389 


Such  doubtful  bacilli  are  more  often  found  in  cultures  from  the  nose 
and  conjunctiva  than  in  those  from  the  throat. 

The  most  distinctive  characteristics  of  the  pseudobacilli  mav  be 
summarized  as  follows :  They  are  apt  to  be  thicker  and  shorter  "than 
true  bacilli,  are  often  arranged  in  parallel  groups;  when  stained  with 
Neisser's  solution  they  show  no  or  only  atypical  polar  granules,  they  do 
not  produce  acid  in  bouillon,  and  are  not  pathogenic  for  guinea-pigs. 

To  such  rules,  however,  there  are  many  exceptions,  and,  as  already 
stated,  bacilli  are  occasionally  found  which  fulfil  all  or  nearly  all  these 
conditions,  and  yet  must  be  classed  as  true  diphtheria. 

The  more  diflScult  cases  fall  naturally  to  the  expert  bacteriologist, 
in  the  absence  of  whom  the  practitioner  must  rely  on  the  clinical  symp- 
toms taken  in  conjunction  with  the  morphological  characteristics  to 
establish  a  diamosis. 

Pathology. — The  pseudomembrane  may  be  situated  on  any  mucous 
surface,  but  most  frequently  on  those  contiguous  to  cutaneous  areas. 
If  the  latter  are  denuded  of  epithelium  they  also  form  suitable  sites  for 
the  propagation  of  disease. 

The  Pseudomembrane. — The  faucial  tonsil  is  the  most  common  site 
of  the  membrane,  together  with  the  adjacent  parts  of  the  pharynx. 
Next,  and  with  about  equal  frequency,  the  nasopharynx,  and  lastly, 
the  larynx  and  trachea.  In  the  severe  so-called  toxic  forms  of  the 
disease  it  often  spreads  to  all  of  these  areas.  It  is  gray  white,  yello\\', 
less  often  dark  in  color.  It  may  be  very  thick  or  practically  invisible; 
clings  closely  to  the  underlying  surface,  or  be  easily  removed  in  large 
flakes;  the  latter  is  characteristic  of  laryngeal  and  tracheal  pseudo- 
membranes. 

The  process  by  which  it  is  formed  is  that  known  as  coagulation 
necrosis,  the  necrosis,  as  a  rule,  involving  only  the  superficial  underlying 
structures.  INIore  rarely  there  may  be  deep  destruction  of  tissue,  a 
process  more  often  seen  when  other  organisms  are  associated  with  the 
Klebs-Loeffler  bacillus.    (See  Plate  IX.) 

On  microscopic  examination  of  a  section  of  tissue,  underlying  a 
diphtheria  membrane,  it  is  seen  that  the  epithelium  beneath  the  latter 
is  destroyed  to  a  great  extent;  there  is  an  extensive  leukocyte  infiltration 
of  the  tissues,  extending  to  a  variable  depth  beneath  the  surface,  together 
with  granular  particles,  remains  of  cell  nuclei,  and  a  greater  or  less 
number  of  red  blood  cells.  Beneath  the  area  of  cell  infiltration  the 
tissues  are  filled  with  fibrinous  exudate  and  red  blood  cells. 

The  change  in  the  bloodvessels  consists  of  thickening  of  the  walls 
and  plugging  of  their  lumen  with  fibrinous  masses.  The  mucous  glands 
may  show  a  mild  form  of  acute  degeneration  or  complete  necrosis  of 
their  structure. 

The  processes  described  are  usually  limited  by  the  membrana  propria, 
but  in  some  cases  this  boundary  is  crossed,  and  the  tissues  beneath  it 
are  invaded  by  fibrin  and  cell  infiltration. 

The  one  characteristic  pathological  change  caused  by  the  toxins  of 
diphtheria  is  that  which  involves  the  nerve  structure.     This  consists  of 


390  ^-V-  .cTiors  diseases 

parenchyiniitous  and  interstitial  degenoration  of  the  peripheral  nerves, 
and  in  all  probability  of  certain  <legenerative  changes  in  the  spinal  cord. 
Other  conditions  that  have  been  described  are  hyperemia,  hemorrhage, 
and  fatty  degeneration.  The  cases  in  which  the  nerves  are  affected 
are  usnallv  tliose  of  long  duration,  or  those  in  which  there  is  extensive 
membrane  production  and  consequent  marked  toxemia. 

In  the  heart  there  may  be  cell  infiltration  of  the  myocardium,  fatty 
infiltration  and  degeneration,  or  interstitial  changes  with  fragmentation 
of  the  uuiscle  fibres. 

Pulmonary  lesions  should  be  considered  rather  as  a  complication 
than  as  a  part  of  the  disease,  for  it  may  be  concluded,  from  the  results 
of  experiments  and  postmortem  bacteriological  findings,  that  in  the 
production  of  these  lesions  the  Klebs-Loeffler  bacillus  j)lays  only  a 
preliminary  part,  the  real  lesion  being  the  work  of  associated  organisms, 
notably  the  streptococcus;  less  often  the  pneumococcus. 

'J'he  lesions  of  the  lymphatic  structures,  spleen,  lymph  nodes,  etc., 
consist  in  brief  of  cell  hyperplasia,  general  congestion  and  areas  of  cell 
necrosis,  so-called  focal  necrosis.  The  latter  is  not  peculiar  to  di])htheria, 
but  may  occin*  in  all  severe  acute  infectious  diseases  if  sufliciently 
prolonged.     Hemorrhages  are  frequently  seen. 

The  diphtheritic  membrane  may  invade  the  alimentary  canal  in  any 
part  of  its  course,  as  an  extension  of  the  disease  from  above  tlownward. 
Diphtheria  of  the  stomach  is  not  infrequently  found  at  autopsies. 

The  lesions  of  the  liver  consist  of  small  areas  of  necrosis  resembling 
to  the  naked  eye  miliary  tubercles  and  due  to  the  action  of  the  specific 
toxin  on  such  areas  of  liver  cells  as  are  supplied  by  bloodvessels  whose 
walls  have  been  affected  by  the  disease. 

In  the  kidneys  there  are  no  lesions  characteristic  of  the  (lis(>ase. 
The  one  most  commonly  found  is  that  of  acute  degeneration  of 
greater  or  less  extent.  Acute  interstitial  lesions  occur  rather  infre- 
quently. 

The  voluntary  muscles  show  similar  changes  to  those  described  as 
occurring  in  the  myocardium. 

Symptomatology. — Many  different  classifications  of  diphtheria  have 
been  attempted,  none  of  which  is  entirely  satisfactory.  The  purely  bac- 
teriological classification,  while  ha^•ing  a  scientific  basis  as  a  recom- 
mendation, leaves  out  of  account  the  variable  reaction  of  different 
constitutions  to  the  same  germs  or  combinations  of  germs.  On  the 
other  hand,  a  classification  based  on  purely  clinical  observation  is 
illogical,  since  only  knowledge  of  the  bacteriological  findings  in  many 
cases  will  enable  us  to  understand  why  those,  seeming  to  all  appearance 
identical,  show  such  a  variation  in  clinical  symptoms. 

For  practical  purposes  the  classification  based  on  the  location  of 
the  membrane  and  the  character  of  the  organism  or  combination  of 
organisms  which  take  part  in  its  formation  is  perhaps  the  most  satis- 
factory. 

Pure  or  fibrinous  diphtheria  is  due  to  the  action  of  the  Klebs-Loeffler 
bacillus  alone,  the  severity  of  the  cases  depending  on  the  extent  of 


DIPHTHERIA 


391 


the  membrane  and  its  location  and  the  degree  of  resistance  shown  by 
the  individual  to  the  action  of  the  toxin. 

This  form  of  diphtheria  is  less  frequently  followed  by  complicaticns, 
yields  more  readily  to  specific  treatment,  and  is  somewhat  more  fre- 
quently seen  amid  more  favorable  surroundings  than  in  institutions  and 
tenements. 

Mixed  diphtheria  is  due  to  the  association  of  the  Klebs-LoefHer 
bacillus  with  other  organisms,  usually  the  streptococcus.  It  is  usually 
characterized  by  its  greater  severity,  the  tendency  to  complications, 
resistance  to  antitoxin,  and  its  proneness  to  attack  those  in  previously 
poor  health,  especially  the  subjects  of  enlarged  lymph  nodes.  It  is  the 
usual  form  which  complicates  scarlet  fever  and  measles  and  is  the  form 
occurring  as  a  primary  disease  of  the  nose. 

The  name  catarrhal  diphtheria  has  been  given  to  that  form  of  the 
disease  in  which  there  is  no  visible  membrane.  It  is  not  of  common 
occurrence  and  derives  its  importance  not  so  much  from  the  danger  to 
the  patient  as  the  probability  of  its  being  transmitted  to  others  in  a  less 
benign  form,  especially  as  the  diagnosis  is  not  usually  made  except 
when  the  nature  of  the  disease  is  suspected,  as  after  the  exposure  of 
the  patient  to  a  known  case  of  diphtheria,  when  the  bacteriological 
examination  serves  to  clear  up  the  nature  of  the  case,  the  symptoms 
being  identical  with  ordinary  catarrhal  pharyngitis. 

General  Symptoms. — The  temperature  curve  of  uncomplicated  diph- 
theria follows  no  particular  course.  In  the  pure  form  of  the  disease  the 
fever  is  not  apt  to  be  high  at  any  time.  Indeed,  in  older  children  unless 
a  careful  record  be  kept,  there  may  appear  to  be  little  or  no  fever, 
in  this  differing  from  the  follicular  tonsillitis.  The  fever  increases  with 
the  formation  and  spread  of  the  membrane,  and  steadily  declines  with 
its  disappearance.  In  younger  children  the  temperature  is  high  for  a 
day  or  two,  after  which  it  slowly  declines.  With  the  appearance  of 
various  complications  there  is  a  rise  of  temperature,  especially  with 
involvement  of  the  lungs.  The  action  of  the  toxin  is  invariably  shown 
by  an  increase  in  the  pulse  rate,  although  the  pulse  may  be  slow  at 
the  onset.  In  very  young  children  it  is  especially  affected.  In  older 
children  a  continuously  high  pulse,  150  or  more  to  the  minute,  may  be 
regarded  as  a  complication.  Other  conditions  of  the  pulse  which  prob- 
ably justify  the  suspicion  of  myocardial  changes  are  bradycardia,  irreg- 
ularity, and  a  weak,  thready  action. 

Blood. — The  toxins  of  diphtheria  produce  certain  chlanges  in  the  blood, 
the  most  constant  of  which  is  a  leukocytosis,  varying  in  degree  with 
the  extent  of  the  membrane,  the  virulence  of  the  individual  organism, 
and  the  amount  of  reactioa  on  the  part  of  the  patient.  The  condition 
begins  with  the  disease  and  reaches  its  height  at  the  height  of  the  latter, 
and  then  gradually  declines.  It  is  prolonged  by  the  occurrence  of 
various  complications,  especially  bronchopneumonia.  The  polynuclear 
elements  are  those  most  affected.  The  increase  of  these  may  be  very 
marked,  especially  in  cases  which  terminate  fatally. 

The  red  cells  are  diminished  to  some  extent,  and  also  the  hemoglobin, 


392  INFECTIOUS  DISEASES 

and,  according  to  some  observers,  the  specific  gravity  of  the  blood  is 
incrojised  t()g(^tlier  with  its  coaguUibihty. 

Urine. — Apart  from  the  various  forms  of  nephritis  which  occur  as  a 
comphcation  of  (Hphtheria,  certain  changes  in  the  urine  are  commonly 
observed  even  in  mild  cases  Jis  a  result  of  toxemia.  The  quantity  may 
be  diminished  to  a  greater  or  less  extent,  occasionally  suppressed. 
Albumin  occurs  in  one-third  to  one-half  of  the  cjises  during  the  course 
of  the  disease.  It  is  usually  small  in  amount,  occasionally  accompanied 
by  casts  and  is  due  to  degeneration  of  the  renal  epithelium.  It  usually 
clears  up  shortly  after  the  disappearance  of  the  membrane.  The  severe 
forms  of  nephritis  are  not  connnonly  seen  in  uncomplicated  cases.  In 
the  mixed  cases  and  especially  when  the  disease  complicates  scarlet 
fever,  nephritis  is  very  common. 

Diphtheria  of  the  Tonsils  and  Pharynx. — ^This  most  common  form 
of  the  disease  varies  in  its  clinical  course  from  an  attack  so  mild  that 
the  children  do  not  seem  to  be  at  all  ill  and  only  an  examination  of  the 
throat  reveals  the  true  nature  of  the  case,  to  that  with  a  rapidly  spread- 
ing membrane  which  includes  the  whole  throat,  and  if  not  treated  at  the 
very  onset  causes  death  by  an  overwhelming  toxemia. 

In  the  mild  form  there  is  seen  on  one  or  both  tonsils  a  white  or  gray 
patch  which  <>ither  covers  the  tonsil  or  resembles  a  punched-out  area 
w^th  membrane  at  the  bottom.  The  tonsil  is  swollen  and  reddened; 
the  membrane  is  usually  friable  and  may  be  removed  in  small  pieces, 
leaving  a  bleeding  surface.  At  times  the  tonsils  present  the  appear- 
ance of  an  acute  follicular  tonsillitis,  so  much  so  that  cultures  alone 
will  serve  to  distinguish  the  two  diseases.  The  membrane  may  remain 
confined  to  the  tonsil  or  spread  to  the  posterior  pillar  of  the  fauces, 
one  or  both  sides  of  the  uvula,  and  back  of  the  pharynx.  Rarely 
it  is  entirely  invisible  by  the  ordinary  methods  of  throat  examination, 
being  concealed  behind  a  swollen  tonsil,  or  is  back  of  tlie  uvula  and 
soft  palate. 

I  have  recently  seen  a  case  in  which  the  throat  presented  every  appear- 
ance of  a  scarlatinal  angina,  both  tonsils  being  bright  red  and  swollen, 
together  with  the  fauces;  an  antitoxin  erythema  added  to  the  difficulties 
of  the  diagnosis.  On  pulling  one  tonsil  slightly  forward  a  large  mem- 
branous patch  was  seen  on  its  posterior  aspect,  the  culture  showing 
Klebs-Ix)effler  bacilli. 

The  symptoms  in  mild  cases  are  not  marked.  The  child,  if  old 
enough,  complains  of  sore  throat  and  some  difficulty  and  pain  in  swal- 
lowing. The  pulse  rate  is  increased,  and  there  are  two  or  three  degrees 
of  fever.  Provided  the  membrane  shows  no  tendency  to  spread,  it 
begins  to  disintegrate  after  a  few  days  to  a  week.  Paralysis,  usually 
confined  to  the  pharynx,  occasionally  follows.  A  moderate  albumin- 
uria is  regularly  present.  The  cervical  lymph  nodes  are  somewhat 
swollen  and  tender   (Fig.  78). 

In  the  severe  form  of  the  disease  the  picture  is  one  of  overwhelming 
toxemia.  The  membrane  may  not  differ  in  appearance  from  that  of 
the  benign  form,  but,  as  a  rule,  is  of  a  dirty  brownish  color,  or  yellowish 


PLATE  X. 


Diphtheria. 


Pseudodiphtheria. 


DIPHTHERIA 


393 


rather  than  white.  The  parts  adjoining  the  tonsils  are  rapidly  involved. 
The  uvula,  posterior  pharynx,  and  fauces  are  covered  by  a  practically 
continuous  thick  membrane,  so  that  when  one  looks  at  the  throat 
the  separate  structures  may  be  almost  unrecognizable.  The  tonsils 
are  greatly  swollen,  and  such  parts  of  them  as  are  not  coated  with  mem- 
brane are'  a  dusky  or  bright  red.  The  u\Tila  is  often  edematous.  The 
process  is  very  liable  to  extend  upward  to  the  nasopharynx.  The  cer- 
vical hnnph  nodes  involved  early  in  the  disease  are  large  and  tender. 

At  the  beginning  of  the  attack  there  may  be  a  chill  or  convulsion. 
There  is  often  a  low  delirium,  followed  by  somnolence;  food  is  taken 
with  great  difBcuky  both  on  account  of  the  narrowing  of  the  passages 


Fig.  78 


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Temperature  chart  of  case  of  diphtheria.    SwelUng  of  lymph  nodes. 

and  the  pain  caused  by  swallowang.     The  pulse  is  rapid  and  small, 
sometimes  irregular.    The  temperature  is  high. 

In  this  form  of  pharjmgeal  diphtheria,  as  in  the  benign,  cuKures  from 
the  throat  will  show  at  least  a  predominance  of  the  Klebs-Loeffler  bacilli. 
Those  taken  from  the  nose  usually  show  a  greater  number  of  cocci. 
When  the  latter  predominate  the  type  of  the  disease  presents  certain 
differences  from  the  form  just  described.  In  the  mixed  form^  of  the 
disease  the  patient  suffers  from  the  combined  effect  of  the  activity  of 
more  than  one  set  of  organisms.  The  membrane  is  apt  to  be  discolored , 
and  it  may  be  even  black  when  there  is  much  hemorrhage  beneath  it. 
It  usually  spreads  rapidly  to  all  adjoining  surfaces.  The  parts  are 
greatly  swollen  and  there  is  a  constant  discharge  from  the  nose  and 


394  INFECTIOUS  DISEASES 

throat  of  a  thin  fluid  mixed  with  mucopus,  hlood,  and  pieces  of  mem- 
brane. The  appearance  of  tlie  patient  is  that  of  one  sufl'ering  from 
general  sepsis.  The  pulse  is  rapid,  the  temperature  of  a  pyemic  type, 
often  very  much  elevated,  showing  marked  and  rapid  remissions. 
The  kidneys  are  affected  early  in  the  disease,  antl  other  complications 
are  frequent. 

Nasal  Diphtheria. — The  common  form  of  this  disease  is  seen  in 
children  past  the  age  of  infancy.  It  is  of  frequent  occurrence  in  insti- 
tutions for  children  and  in  schools,  probably  much  more  so  than  is 
generally  supposed.  When  it  is  confined  to  the  nasopharynx  and 
anterior  nares  the  children  seem  to  be  sufl^ering  from  an  aggravated 
rhinitis.  There  is  a  constant  nasal  discharge  of  a  thin  or  mucopurulent 
character,  often  mingled  with  blood  and  causing  excoriation  of  the  nos- 
trils and  upper  lip.  There  is  more  or  less  obstruction  to  nasal  respira- 
tion and  consequent  mouth  breathing.  The  patients  do  not  seem  par- 
ticularly ill,  as  a  rule  merely  uncomfortable.  There  may  be  a  moderate 
toxemia,  which  Is  shown  by  lassitude,  headache,  anorexia,  and  slight 
fever.  The  nature  of  the  disease  is  often  no  doubt  overlooked,  and 
can  only  be  determined  by  a  bacteriological  examination,  althougii 
occasionally  a  careful  inspection  of  the  anterior  nares  will  reveal  the 
presence  of  membrane,  usually  on  the  septum  and  deep  in  the  canal, 
and  the  lymph  nodes  below  the  angle  of  the  jaw  will  be  found  enlarged. 
The  mucous  membrane  is  reddened  and  swollen.  The  cultures  usually 
show  mixed  infection.  The  process  may  extend  to  the  nasopharynx 
and  even  to  the  larynx.  These  patients  are  a  source  of  grave  danger 
to  those  with  whom  they  come  in  contact.  Their  handkerchiefs  and 
fingers,  constantly  saturated  with  the  infected  discharges,  are  eminently 
suited  to  spread  the  disease. 

When,  instead  of  being  confined  to  the  anterior  and  posterior  nares, 
these  parts  are  secontlarily  infected  from  disease  of  the  lower  pharynx 
and  tonsils,  the  sjanptoms  are  of  great  severity,  especially  as  it  is  the 
type  of  disease  seen  most  frequently  in  young  children.  If  nurslings, 
they  are  unable  to  take  nourishment,  the  mouth  is  held  widely  open, 
the  respiration  snuffling  and  snoring.  The  children  are  unable  to  rest, 
tossing  restlessly  from  side  to  side.  There  is  real  obstructive  dyspnea, 
the  air  not  being  able  to  enter  the  nose  at  all,  and  only  insufficiently 
the  mouth.  On  inspiration  there  may  be  recession  at  the  epigastrium, 
though  usually  not  so  marked  as  that  seen  in  laryngeal  diphtheria. 
There  is  marked  toxemia.  The  children  are  pale,  apathetic,  with 
cyanotic  lips  and  extremities;  the  pulse  is  rapid  and  feeble.  The  tem- 
perature is  high.  The  lymph  nodes  of  the  neck  are  swollen.  The  chil- 
dren may  die  of  toxemia,  suffocation,  or  finally  of  extension  of  the 
disease  to  the  larynx  (Fig.  70). 

Laryngeal  Diphtheria. — The  term  croup  may  be  applied  correctly 
as  a  purely  clinical  description  of  an  acute  laryngeal  obstruction,  due 
to  inflammation  of  the  mucous  membrane,  together  with  spasm  of  the 
vocal  cords.  Membranous  croup  may  be  caused  by  the  Klebs-Ivoeffler 
bacillus,  either  alone  or  in  combination  with  other  organisms,  or  very 


DIPHTHERIA 


395 


Fig. 

79 

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rarely  by  the  streptococcus  alone,  and  usually  as  a  complication  of  one 

of  the  exanthemata.     In  order  to  avoid  ambiguity  it  is  perhaps  better 

to  employ  the  terms  diphtheritic  and 

non-diphtheritic     for     membranous 

croup,  and  limit  the  term  catarrhal 

to  that  form  of    the  disease  which 

is    due    to    simple    acute    catarrhal 

inflammation  or  congestion  of    the 

larynx. 

Diphtheritic  membranous  croup 
is  met  with,  as  a  rule,  as  an  exten- 
sion of  the  disease  from  the  throat 
or  nose.  Less  frequently  the  first 
symptoms  noticed  are  those  refer- 
able to  the  larynx,  the  throat  only 
being  slightly  congested  or  abso- 
lutely normal.  In  the  first  instance 
the  pharyngeal  or  nasal  diphtheria 
may  run  for  several  days  or  even 
weeks  before  extending  to  the  larynx, 
or  it  may  do  so  in  a  few  hours. 
Wliether  secondary  or  primary,  the 
occurrence  of  laryngeal  involvement 
produces  a  fairly  definite  train  of 
symptoms  only  varying  in  the  rap- 
idity with  which  they  follow  one  another  or  are  modified  by  local  or 
general  treatment. 

The  course  of  laryngeal  diphtheria  may  logically  be  divided  into 
three  fairly  well-defined  stages.  In  the  first  stage  there  is  a  hoarse, 
croupy  cough,  differing  not  at  all  from  that  so  commonly  observed  in 
children  at  the  onset  of  an  attack  of  catarrhal  laryngitis  or  tracheo- 
bronchitis. In  the  rare  instances  when  a  view  has  been  had  of  the 
larynx  at  this  stage  there  has  been  seen  congestion  of  the  mucous  mem- 
brane and  vocal  cords.  Cultures  at  this  stage,  unless  special  care  be 
taken  to  introduce  the  swab  actually  within  the  larynx,  often  prove 
negative,  even  though  later  cultures  show  Klebs-LoeflSer  bacilli  frequently 
in  pure  culture.  The  duration  of  this  stage  varies  from  a  few  hours  to 
a  day  or  two. 

The  second  stage  corresponds  to  the  formation  of  the  pseudomem- 
brane  within  the  larynx.  The  cough  increases  in  frequency.  It  is 
brought  on  by  disturbing  the  patient,  by  the  taking  of  food  or  medicine, 
and  by  exposure  to  draughts  and  by  crying,  It  is  paroxysmal  in  character, 
and  distinctly  laryngeal,  the  patient  acting  as  though  particles  of  dust 
or  other  foreign  substance  were  irritating  the  larynx.  The  cough  is 
dry  and  ineffectual.  During  the  attack  the  face  becomes  red  or  dusky, 
the  bloodvessels  become  prominent,  and  the  eyes  bulge  and  lacrymate. 
There  is  soon  developed  partial  or  complete  loss  of  voice ;  the  respira- 
tion has  a  sibilant  character  as  though  a  large  volume  of  air  was  being 


Diphtheria  wiih  toxemia. 


396 


INFECTIOUS  DISEASES 


luirri(>(l  tliroufxh  a  small  tube.  The  expiration  is  riule,  and  the  ])ause 
between  inspiration  and  expiration  is  niarkech  Even  at  this  stage,  if 
the  eliikh'en  are  kept  perfeetly  quiet,  tlieir  breathing  is  not  so  very 
labored  during  a  great  part  of  the  time,  but  from  time  to  time  exaeer- 
bations  of  dyspnea  occur,  during  which  the  children  toss  about,  their 
face  expressing  great  anxiety,  the  mouth  partly  open,  chest  heaving, 
the  accessory  muscles  of  respiration  taking  part  in  tlie  process.  At  the 
height  of  inspiration  there  will  be  noted  a  marked  recession  of  the  soft 
parts  at  the  epigastrium  and  above  the  clavicles.  The  respiratory 
murmur  at  the  bases  of  the  lung  on  auscultation  will  be  found  to  be 
diminished.  After  the  attack  passes  the  child  sinks  back  exhausted. 
It  is  repeated  at  shorter  and  shorter  intervals.  Occasionally  the  auto- 
matic expulsion  of   pseudomembrane  terminates  the  attack  (Fig.  <S0). 


Fig.  80 


September 


DATE 

'i 

3 

4 

5 

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1 

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Larj-ngeal  diphtheria.    Expulsion  of  membrane. 


From  postmortem  examinations  of  the  larynges  of  children  who 
have  died  at  this  stage,  it  is  seen  that  the  amount  of  membrane  within 
the  larynx  and  involving  the  vocal  cords  can  by  no  means  be  estimated 
from  the  character  of  the  symptoms.  With  the  severest  variety  of  laryn- 
geal dyspnea  there  may  be  only  moderate  superficial  ulceration  of 
the  cords  and  little  or  no  membrane  external  to  them,  the  larynx 
being  invariably  congested.  On  the  other  hand,  the  membrane  may 
be  found  to  extend  from  the  larynx  in  a  continuous  laver  even  beyond 
the  bifurcation  of  the  trachea.  Such  great  extent  of  membrane,  how- 
ever, is  to-day  rarely  seen,  except  in  such  cases  as  have  not  received 
antitoxin  at  all  or  too  late  in  the  disease  to  be  effectual. 

In  the  third  .stage  dyspnea  is  marked  and  con.stant.  The  exacerba- 
tions and  remi.ssions  of  the  previous  stage  are  not  .seen.  The  resj)ira- 
tion  is  carried  on  with  great  difficulty,  all  the  acccs.sory  mu.scles  being 
constantly  called  upon.  The  child  sits  up,  or  tosses  from  side  to  side. 
The  recessions  previously  noted  are  more  marked  and  constant.  The 
inspiration  and  expiration  are  noisy  and  perfectly  typical  of  the  disea.se. 


DIPHTHERIA  397 

It  is  now  evident  that  there  is  a  continual  lack  of  oxygen  reaching 
the  lungs.  The  lips  and  fingers  are  blue,  the  skin  bathed  in  perspira- 
tion, the  pulse  rapid  and  feeble.  If  the  condition  be  not  relieved  by- 
surgical  means,  symptoms  of  carbonic  acid  poisoning  soon  develop  and 
the  patient  lies  quietly,  almost  lifeless,  except  when  an  attack  of  cough- 
ing arouses  him  to  feebler  and  feebler  efforts  to  overcome  the  obstruc- 
tion. He  becomes  almost  pulseless,  the  face  dusky,  the  skin  clammy, 
the  stupor  deepens  into  coma,  and  the  patient  ceases  to  breathe.  A 
convulsion  occasionally  ends  the  scene. 

In  explanation  of  the  cause  of  laryngeal  stenosis  several  theories 
have  been  offered.  Those  which  have  met  with  most  general  accept- 
ance are  briefly  as  follows:  In  the  earlier  stages  of  the  disease,  before 
the  formation  of  pseudomembrane,  a  certain  amount  of  obstruction 
is  due  to  the  swelling  of  the  mucous  membrane  of  the  larynx  and  con- 
gestion of  the  vocal  cords.  The  exacerbations  of  dyspnea  are  at  this 
stage  wholly  due  to  spasm  of  the  cords  which  in  some  way,  not  under- 
stood, have  been  rendered  hypersensitive  to  stimulus.  Such  a  condition 
may  be  seen  also  in  whooping-cough.  At  a  later  stage,  when  the  dyspnea 
is  unremitting,  it  is  due  to  the  obstructing  membrane  and  increased 
swelling  of  the  parts,  although  the  spasmodic  element  is  still  in  evidence. 
In  the  final  stage  the  latter  does  not  come  into  play;  the  muscles  as  well 
as  the  skin  of  the  body  appear  wholly  irresponsive  to  stimulation,  due, 
it  is  believed,  to  systemic  carbonic  acid  poisoning,  and  the  dyspnea  is 
then  wholly  caused  by  the  narrowing  of  the  calibre  of  the  laryngeal 
passage  by  congestion,  pseudomembrane,  and  often  by  edema  below  the 
larynx.  Upon  this  theory  it  is  easy  to  explain  the  temporary  relief 
afforded  in  the  early  stages  by  measures  taken  for  the  relief  of  spasm, 
such  as  the  administration  of  emetics  and  sedatives,  the  applications  of 
heat  and' steam,  and  the  enforcement  of  perfect  freedom  from  excitement 
of  any  kind;  while  the  importance  of  the  role  played  by  the  laryngeal 
membrane  in  the  late  stages  of  the  disease  is  shown  by  the  relief  of  all 
symptoms  on  the  rare  occasions  when  the  membrane  has  been  expelled 
by  coughing. 

Diphtheria  of  the  Trachea  and  Bronchi. — The  laryngeal  pseudomem- 
brane may  extend  downward,  involving  the  trachea,  the  larger  and  even 
the  smallest  bronchi.  The  name  "ascending  croup"  has  been  given  to 
a  rare  condition  in  which  the  diphtheritic  membrane  apparently  first 
finds  lodgement  in  the  trachea  or  bronchi,  and  secondarily  involves 
the  larynx.  Such  a  condition  can  only  be  positively  diagnosticated  by 
the  coughing  up  of  a  tracheal  or  bronchial  cast  with  a  relief  of  all  the 
symptoms,  but  this  state  of  affairs  may  be  suspected  when  intubation 
or  tracheotomy  has  failed  to  overcome  the  dyspnea,  or  occasionally  by 
actually  seeing  the  membrane  through  the  tracheotomy  wound.  The 
only  characteristic  physical  sign  is  that  produced  by  occlusion  of  a 
large  bronchus  with  consequent  diminished  or  absence  of  breathing 
over  that  part  of  the  pulmonary  surface  to  which  its  ramifications  lead. 
The  symptoms  are  rapid  breathing  with  real  unremitting  dyspnea, 
unrelieved  by  operation,  and  evidences  of  profound  toxemia. 


398 


INFECTIOUS  DISEASES 


Conjundwal  Diphtheria. — This  occurs  either  as  a  primary  disease 
or  follows  infection  carried  by  the  hand  from  the  nose  or  throat.  Three 
forms  have  been  described.  That  most  commonly  seen  is  in  part,  at 
least,  a  true  interstitial  process  and  is  probably  always  due  to  mixed 
infection.  The  lids  are  stiff  and  thickened,  so  that  their  eversion  is 
difficult  and  frecpiently  impossible  witiiout  using  a  great  deal  of  force. 
The  conjunctiva  of  one  or  both  lids  is  covered  with  a  closely  adherent 
blood-flecked  membrane  of  a  dirty-gray  color,  and  there  is  a  profuse 
purulent  disciiarge.  After  the  detachment  of  the  membrane  ulcera- 
tions, adhesions,  and  cicatrices  may  be  left  or  the  sight  permanently 
destroyed  (Fig.  81).  In  the  second  and  less  severe  form  the  mem- 
brane is  usually  white,  less  adherent,  the  lids  not  thickened  to  any 
great  extent,  and,  except  for  the  presence  of  the  membrane,  the  cases 
resemble  those  of  acute  catarrhal  conjimctivitis.  Complications  are 
not  common  under  proper  treatment.  In  the  third  form  there  is  no 
visible  membrane,  the  conjunctiva  is  swollen,  and  there  is  a  thin,  glairy 
discharge,  with  no  evidence  of  epithelial  desquamation.    This  form  of 


Fig.  81 


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puusE  Sl^zs^llSSssSs^S^SiSSi 

Rtsp.     5SSS^'$gSSg8§S3§"^S^:?3?3 

Conjunctival  diphtheria. 

the  disease  is  probably  not  common  and  can  only  be  diagnosticated  by 
culture.  Gonococci  and  staphylococci  may  be  associated  with  the 
Klebs-Loeffler  bacillus,  but  very  frequer.tiy  the  latter  is  foimd  in  pure 
culture,  except  in  the  first  form  of  the  disease.  The  symptoms  in 
general  are  as  follows:  The  eyes  are  closed,  the  bulbs  tender  on  pressure; 
when  the  lids  are  forced  apart  there  is  photophobia  and  epiphora,  and  the 
cheeks  are  often  excoriated  from  the  irritating  discharge  from  l)etween 
the  lids.  The  constitutional  symptoms  consist  of  a  moderate  rise  in 
temperature  and  pulse  rate  and  other  evidences  of  slight  toxemia. 

Diphfheria  of  the  Genitals. — This  invariably  occurs  as  the  result  of 
autoinoculation  from  other  sites.  The  disease  is  not  a  common  one, 
and  is  seen  most  frequently  in  little  girls.  The  membrane  extends 
over  both  labia  majora  and  minora,  and  occasionally  to  the  vagina 
and  anal  margin.  The  parts  are  sw^ollen,  painful,  and  bleed  easily. 
The  inguinal  lymph  nodes  are  usually  invohed. 

Diphfheria  of  the  Mouth. — This  is  occasionally  seen  in  severe  cases 
of  mixed  infection  occurring  in  the  course  of  the  exanthemata  (scarlet 


DIPHTHERIA  399 

fever,  measles,  etc.).  The  patches  are  on  the  mucous  membrane  of 
the  cheek,  Hps,  and  tongue,  and  invohnxig  fissures  about  the  corners  of 
the  mouth  and  Hps.  The  mucous  membrane  is  reddened  and  bleeds 
easily.  There  is  an  increased  flow  of  saliva  and  the  breath  has  an  odor 
similar  to  that  in  ulcerative  stomatitis.  The  submaxillarv  hmph  nodes 
are  swollen,  often  to  a  great  degree. 

Diphtheria  of  Wounds. — ^This  is  seen,  as  already  mentioned,  as  an 
extension  of  the  disease  from  within  the  mouth  to  fissures  about  the 
lips.  It  also  occurs  m  abrasions  about  the  ear  and  nose,  but  mav  involve 
any  cutaneous  surface  denuded  of  epithelium  bv  scratchino-,  eczema, 
herpes,   etc. 

Diphtheria  of  the  Ear. — The  Klebs-Loefiier  bacillus  has  been  found 
in  a  large  number  of  cases  in  the  middle  ear  in  cultures  taken  after 
death  from  diphtheria.  It  is  usually  associated  •v\*ith  other  organisms 
of  the  pyogenic  variety  and  is  merely  an  evidence  of  general  infection, 
there  being  no  true  pseudomembrane  present.  In  these  cases  the  sjinp- 
toms  during  life  have  been  those  of  an  ordinary  suppurative  otitis  media. 

A  few  cases  of  true  diphtheritic  infection  have  been  described  with 
membrane  to  be  seen  deep  within  the  meatus  after  the  rupture  of  the 
drum.  There  is  a  bloody,  irritating  discharge  which  excoriates  the 
canal  and  external  ear.  As  to  whether  this  disease  is  carried  by  way 
of  the  Eustachian  tube  or  the  blood  and  l}Tnph  stream  there  is  ground 
for  a  difference  of  opinion,  as  in  some  cases  the  former  has  appeared 
to  be  perfectly  normal  when  diphtheria  was  found  in  the  middle  ear. 

Complicating  Diphtheria. — Measles,  scarlet  fever,  and  less  fre- 
quently whooping-cough  render  a  patient  very  susceptible  to  diph- 
theria infection,  the  natural  protective  barrier  of  the  healthy  mucous 
membrane  being  destroyed  by  the  inflammatory  processes  accom- 
panpng  the  primary  disease.  The  association  of  measles  and  scarlet 
fever  with  diphtheria  is  one  much  to  be  dreaded.  The  t^'pe  of  the 
disease  is  invariably  that  of  a  mixed  infection,  the  streptococcus 
being  responsible  for  the  character  of  the  local  and  systemic  symp- 
toms. In  this  type  severe  complications  are  the  rule.  There  is  usually 
great  involvement  of  the  l}Tnph  nodes,  with  suppuration  and  sloughing 
of  the  involved  tissues.  Gangrenous  processes  are  occasionally  seen, 
invohing  especially  the  maxillae,  adjoining  soft  tissues,  and  the  ear. 
Bronchopneumonia  is  not  uncommon,  and  also  general  septicemia. 

Complications  and  Sequelae.  Xervous  Si/stem. — Taking  an  average 
of  a  large  number  of  cases,  compiled  by  different  observers,  postdiph- 
theritic paralysis  may  be  said  to  occur  in  about  15  per  cent,  of  diph- 
theria cases.  Accuracy  in  regard  to  this  is  not  possible,  as  a  number 
of  such  cases  undoubtedly  develop  after  the  patients  have  passed  from 
observation.  The  symptom  usually  occurs  during  the  stage  of  con- 
valescence. It  may  recur  as  early  as  the  second  day,  and  even  after  a 
month. 

The  cases  are  usually  di^-ided  into  a  discrete  or  local  form  and  severe 
or  general  form.  The  first,  by  far  the  more  frequent,  usually  occurs 
earlier  in  the  disease  than  the  latter.     The  palatal  muscles  are  those 


400 


INFECTIOUS  DISEASES 


most  often  involved,  and  even  when  the  paralysis  develops  into  a 
general  one  the  palate  is,  as  a  rule,  first  afl'eeted.  The  first  symptom 
noted  is  that  the  children  appear  to  have  difficulty  in  swallowing,  and 
that  liquid  food  causes  an  attack  of  spasmodic  coughing  and  returns 
throuo-h  the  nose.  On  inspecting  the  throat  it  is  seen  that  the  uvula 
hangs  down  in  a  relaxed  condition  and  does  not  respond  to  stimulus. 
This  condition  is  recovered  from  in  a  few  weeks.  There  is  slight  danger 
of  an  aspiration  pneumonia  being  caused  by  it. 

In  the  general  form  of  paralysis  the  involvement  of  other  groups  of 
muscles  usually  follows  that  of  the  palate.  The  muscles  of  the  pliarynx 
and  larynx  usually  come  next  in  frc(juency,  and  then  those  of  the 
lower  extremities  and  the  eye.  The  patellar  reflexes  are  regularly  hjst, 
anfl  there  may  be  paresthesia  or  complete  anesthesia  of  the  limbs.  'I'he 
children,  if  allowed  out  of  bed,  either  walk  awkwardly  with  a  shuffling 
gait  or  are  entirely  unable  to  stand.  Any  or  all  of  the  ocular  muscles 
may  be  affected  on  one  or  both  sides,  in  consetjuence  of  which  there  is 
ptosis,  strabismus,  hypermetropia,  myopia,  and  inequality  of  the  pupils. 
The  muscles  of  the  uj)per  extremity  are  less  often  involved  than  the 
lower.  When  this  takes  place  the  paralysis  is  usually  total,  with  abso- 
lute loss  of  nniscular  power;  the  patient  not  able  to  sit  up  or  support 
the  head,  to  speak,  or  to  swallow. 

Paralysis  of  the  diaj)hragm  usually  occurs  in  connection  with  the 
involvement  of  other  muscles.  The  rcs{)iration  is  purely  thoracic 
and  carried  on  })y  voluntary  effort.  During  iiisj)iration  instead  of  the 
normal  bulging  of  the  abdomen  there  is  a  recession  in  this  region,  and 
with  contraction  of  the  chest  the  abdomen  bulges.  There  is  a  real  and 
painful  dyspnea,  and  much  anxiety  on  the  part  of  the  patient;  the 
respirations  are  shallow  and  irregular.  The  prognosis  in  these  cases  is 
not  good  on  account  of  the  fact  that  cardiac  paralysis  is  not  an  infre- 
quent accompaniment.  The  latter  may  occur  at  any  stage  of  the  dis- 
ease, but  is  apt  to  be  delayed  until  convalescence  is  well  established. 
It  occurs  as  a  part  of  a  general  paralysis  or  by  itself. 

"^rhe  involvement  of  the  pneumogastric  nerve  is  shown  l)y  vomiting 
and  abdominal  j)ains.  In  tlie  milder  form  the  pulse  may  be  only  weak 
or  irregular,  with  a  tendency  to  syncoy)e.  In  the  severe  form  the  pulse 
may  be  very  slow  or  very  ra[)id,  markedly  irregular,  thready,  or  inter- 
mittent. Various  nnirmurs  iire  heard  over  the  precordium.  The 
respiration  is  raj)id;  the  patient  is  terribly  anxious,  tossing  about  or 
lying  apparently  lifeless.  Sudden  death  may  take  place  at  any  time, 
either  with  or  without  previous  exertion.  The  prognosis  in  the  severe 
forms  is  not  good. 

The  paralyses,  referable  to  the  cerebrum,  are  the  result  of  hemor- 
rhage, embolism,  or  thrombosis,  due,  as  already  y)ointed  out,  to  altera- 
tion in  the  character  of  the  blood.  They  usually  occur  during  con- 
valescence. 

Pulmonary  fjcsions.  It  may  be  stated  ns  a  very  general  rule  that 
there  are  few  fatal  cases  of  diphtheria  which  do  not  show  the  pres- 
ence of  pneumonic  lesions  as  a  contributing  or  direct  cause  of  death. 


DIPHTHERIA 


401 


This  complication  occurs  very  much  more  frequently  in  hospitals  and 
institutions  than  outside  of  them,  in  children  under  one  year  of  age 
than  in  older  ones,  in  mixed  infections  than  in  pure  diphtheria,  in 
laryngeal  cases,  and  especially  those  which  have  been  operated  on, 
than  when  the  disease  is  locateil  elsewhere;  much  more  fre(|uentlv  in 
winter  and  spring  than  in  the  warm  months,  and  in  those  institutions 
in  which  no  attempt  is  made  to  isolate  cases  having  this  complication 
from  those  who  have  not,  and  finally  more  often  in  cases  not  treated 
by  antitoxin  or  treated  late  in  the  disease  than  those  who  are  so  treated 
at  an  early  stage.  Thus  it  may  be  seen  that  any  statistics  as  to  the 
occurrence  of  complicating  pneumonia  are  of  little  value  unless  the 
al)ove  factors  be  taken  into  account  (Fig.  82).  The  symptoms  do  not 
differ  from  those  of  secondary  bronchopneumonia  complicating  other 


Fig.  82 


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Diphtheritic  bronchopneumonia. 

acute  infectious  diseases.  Inhere  is  an  increase  in  the  r(,\spirations, 
which  aw  usually  ")()  or  more  to  the  minute,  together  with  an  increase 
in  tiie  pulse  rate  and  a  rapid  rise  in  temperature.  The  rcspiralion- 
pulse  ratio  appriiaches  i)ne  to  three  tir  one  to  two.  The  prostration  is 
increased. 

In  laryngeal  cases  the  cyanosis  is  increased;  the  physical  signs  may 
be  obscured  by  the  transmission  of  sounds  to  the  chest  wall  from  the 
larynx,  especially  in  intubated  cases;  so  that  the  diagnosis  nmst  be  based 
rather  on  the  symptoms  than  the  results  of  physical  examination.  A 
greater  part  of  one  or  both  lobes,  generally  the  lower,  is  usually  in- 
voIvimI  in  severe  cases.  There  is  usually  also  more  or  less  pleurisy, 
especially  in  the  more  chronic  cases. 

Bronchitis  is  a  rather  freipient  accompaniment  of  diphtheria.  Its 
importance  is  due  to  the  fac-t  that,  particularly  in  younger  children,  it 
20 


402  INFECTIOUS  DISEASES 

shows  a  great  tendency  to  spread  downward  to  the  smaller  hronclii 
and  air  vesicles.  Emphysema  of  a  vesicular  type  is  occasionally  seen 
at  autopsy,  especially  in  operated  laryngeal  cases  and  when  pneumonia 
is  present  in  other  parts  of  the  lungs. 

Diagnosis  (Clinical). — There  are  a  number  of  conditions  so  closely 
resemi)liiig  true  diphtheria  that  no  matter  how  great  the  experience  of 
the  physician  it  will  not  enable  him  to  arrive  at  a  correct  diagnosis 
save  by  a  bacteriological  examination  in  the  more  obscure  cases.  On 
the  other  hand,  the  great  majority  of  cases  of  laryngeal  and  pharyngeal 
diphtheria  may  be  diagnosticated  on  the  local  and  clinical  symptoms, 
and  it  is  to  be  remembered  that,  in  a  disease  in  which  every  hour's 
delay  in  administering  specific  treatment  adds  to  the  patient's  danger, 
it  is  not  always  advisable  to  wait  for  the  result  of  cultures. 

The  clinical  diagnosis  of  pharyngeal  and  nasal  diphtheria  is  based 
on  the  character  of  the  membrane  already  described,  on  its  tendency 
to  spread  to  adjacent  parts,  the  condition  of  the  pulse  and  tempera- 
ture, and  evidences  of  toxemia.  Follicular  tonsiUitis,  especially  when 
the  individual  areas  tend  to  coalesce  and  resemble  a  membrane,  may 
not  infreciuently  be  confused  with  diphtheria.  In  the  former,  however, 
both  tonsils  are  usually  involved  sinndtaneously,  there  is  no  tendency  to 
spread  to  other  parts,  the  individual  crypts  of  the  tonsil,  filled  with  cells 
and  detritus,  may  usually  be  made  out,  and  when,  by  the  coalescence 
of  such  detritus,  there  is  an  apparent  membrane,  the  latter  may  readily 
be  brushed  off,  as  it  is  not  adherent.  The  constitutional  symptoms 
come  on  very  much  more  quickly  and  violently  than  is  the  rule  in  diph- 
theria; there  is  sudden  high  fever,  headache,  pain  in  the  joints,  and 
the  patient  feels  very  ill.  It  rarely  occurs  in  very  young  children. 
There  is  a  rare  form  of  true  diphtheria  which  so  closely  resembles  follic- 
ular tonsillitis  that  a  clinical  diagnosis  is  not  possible.  Non-diphtheritic 
meml)ranous  tonsillitis  occurs  in  the  majority  of  cases  in  the  course  of 
the  acute  exanthemata,  notably  scarlet  fever  and  measles.  It  is  due 
to  the  pyogenic  cocci  and  may  occur  as  a  primary  disease.  When  it 
occurs  secondarily  to  the  exanthemata,  its  true  nature  may  be  sus- 
pected, but  as  true  diphtheria  not  infre(|uently  complicates  these  dis- 
eases too  much  reliance  should  not  be  placed  on  the  clinical  diagnosis, 
and  cultures  should  be  invariably  taken.  In  the  primary  cases  it  is 
not  possible  to  distinguish  the  condition  from  that  of  true  diphtheria. 
The  membrane  is  usually  seen  on  the  tonsil  and  shows  perhaps  less 
tendency  to  spread  than  in  the  latter  disease.  The  symptoms  do  not 
serve  to  make  a  differential  diagnosis. 

Circumtonsilar  abscess  occasionally  bears  some  resemblance  to  diph- 
theria, especially  as  there  may  be  more  or  less  membrane  on  the  tonsil 
due  to  the  growth  of  pyogenic  cocci.  The  clinical  picture,  however, 
is  generally  fairly  typical.  The  tonsil  usually  at  one  side  is  pushed 
toward  the  middle  line;  it  is  congested  as  well  as  the  mucous  membrane 
above  it.  There  is  diflSculty  in  opening  the  mouth  and  the  speech 
resembles  that  of  a  person  speaking  with  his  mouth  full.  Evacuation 
of  the  pus  is  followed  by  immediate  relief. 


DIPHTHERIA  493 

Herpes,  sprue,  and  ulcerative  stomatitis  may  occasionally  be  con- 
founded with  buccal  diphtheria.  In  cases  of  doubt  the  diagnosis 
should  rest  upon  culture.  The  rather  rare  ulceration  of  the  tonsil  due 
to  the  bacillus  of  Vincent  need  only  be  referred  to  as  occasionally  mis- 
taken for  diphtheria.  This  together  with  tuberculous  and  syphilitic 
lesions  are  to  be  differentiated  by  the  history  of  the  case  and  finally  by 
culture. 

Diphtheritic  Croup. — No  description,  written  or  oral,  however  graphic, 
can  take  the  place  of  actual  observation  of  one  or  more  cases  of  this 
condition  in  enabling  the  physician  to  recognize  it  almost  at  a  glance. 
So  characteristic  are  the  symptoms,  that  only  lack  of  familiarity 
with  them  can  excuse  a  failure  to  recognize  them  after  the  signs  of 
stenosis  are  well  marked.  The  symptoms  have  already  been  described. 
Those  of  most  importance  in  arriving  at  a  diagnosis  are  the  character 
of  the  cough;  the  somewhat  slow,  insidious,  and,  notwithstanding  fre- 
quent remission,  steady  increase  in  the  symptoms  of  stenosis ;  the  pres- 
ence, as  a  rule,  of  membrane  on  the  tonsils  or  pharynx,  and,  when 
stenosis  is  well  established,  the  recession  at  the  epigastrium  and  clavicles. 

Cases  of  membranous  croup  due  to  other  organisms  than  the  Klebs- 
LoeflBer  bacillus  are  occasionally  reported;  usually  they  occur  as  a  com- 
plication of  scarlet  fever  or  measles  or  other  exanthematous  diseases. 
Doubtless  this  condition  has  been  more  frequently  diagnosticated  than 
the  known  facts  would  seem  to  justify.  The  uncertainty  of  early 
laryngeal  culture  has  already  been  pointed  out,  and  in  my  opinion 
this  fact  is  accountable  for  many  of  the  cases  of  membranous  laryngitis 
being  reported  as  non-diphtheritic.  In  membranous  laryngitis  without 
membrane  in  the  pharynx  subsequent  cultures  will  almost  invariably 
show  the  Klebs-IiOeffler  bacillus,  even  if  the  first  are  negative  or  show 
the  presence  of  a  few  cocci.  While  this  condition  undoubtedly  is  occasion- 
ally met  with,  nevertheless  the  diagnosis  of  membranous  croup  diie  to 
any  other  organism  than  the  diphtheria  bacillus  should  be  made  with 
the  greatest  reservation. 

Catarrhal  croup  may  be  mistaken  for  true  diphtheritic  laryngitis.  In 
the  former,  however,  the  attack  comes  on  very  suddenly,  either  without 
a  history  of  previous  illness  or  one  of  mild  catarrhal  trouble  or  indiges- 
tion shortly  before.  The  child  is  awakened,  usually  at  night,  with 
sudden  symptoms  of  suffocation,  a  characteristic  barking  cough,  partial 
aphonia,  and  intense  anxiety.  If  the  true  condition  be  suspected,  the 
administration  of  an  emetic,  a  hot  mustard  bath,  with  steam  inhalation, 
will  promptly  relieve  the  symptoms.  The  next  morning  the  child  will  be 
in  comparatively  normal  health,  though  the  attack  is  apt  to  recur  the 
following  night,  and  sometimes  lasts  for  a  night  or  two  more. 

Retropharyngeal  abscess  is  occasionally  mistaken  for  laryngeal 
croup.  In  the  former  the  child's  head  is  thrown  back,  the  mouth  held 
open,  the  voice  likened  to  the  quacking  of  a  duck.  On  digital  exami- 
nation of  the  throat  there  will  be  found  at  the  back  of  the  pharynx, 
in  the  middle  line  or  at  one  side,  a  characteristic  fluctuating;  tumor. 
Evacuation  of  the  pus  produces  immediate  relief. 


404  INFECTIOUS  DISEASES 

Bronchopneumonia  is  not  infre(|uiMitly  mistaken  for  membranous 
laryngitis,  and  intubationists  are  not  unconnnonly  called  ujjon  to  ojierate 
on  such  cases.  There  is  dyspnea  in  both,  cyanosis,  recession  of  the 
soft  parts  of  the  chest,  and  evidences  of  toxemia.  Here,  however,  the 
resemblance,  as  a  rule,  ends,  and  a  kno\vled<i;e  of  the  syni])tonis  and 
siiins  of  the  two  diseases  should  enable  one  to  avoid  mistakes  in  dia(^- 
nosis. 

Nosal  Diphtheria. — This  disease  may  be  suspected  when  a  mem- 
brane cannot  be  seen  in  the  nares,  if  a  nasal  discharge  persists  with 
marked  obstruction,  and  especially  when  the  former  is  freely  mixed 
with  blood  and  pus  and  causes  excoriations  of  the  nostrils  and  lips. 
Nevertheless,  the  diagnosis  can  only  be  confirmed  by  culture  taking. 
In  a  postnasal  case  with  enlarged  lymph  nodes  if  the  child  will  allow  a 
laryngoscopic  examination  it  will  help  clear  up  the  diagnosis.  Severe 
acute  cases  usually  follow  a  pharyngeal  or  tonsillar  diphtheria,  and  are, 
therefore,  not  difficult  to  recognize. 

Diagnosis  (Bacteriological). — From  what  has  been  said  of  the  protean 
character  of  the  sym])t()ms  of  diphtheria,  it  should  be  evident  that  for 
puriioses  of  exact  diagnosis  the  clinical  symptoms  must  in  many  cjises 
be  secondary  in  importance  to  the  knowledge  oi)lained  by  bacteriology. 
When  it  is  essential  to  make  an  inuncdiate  diagnosis  the  direct  method 
may  be  employed,  the  results  of  which,  however,  are  by  no  means 
always  satisfactory.  For  this  purpose  a  forceps  or  regular  culture 
swab,  wound  ^\'itll  absorbent  cotton,  is  passed  over  the  suspected 
surface,  removing,  if  possible,  a  bit  of  membrane.  A  drop  of  clean 
water  is  thvn  placed  on  a  cover-glass  or  microscopic  slide,  and  a  smear 
made  on  the  surface.  This  is  passed  through  the  flame  in  order  to  fix 
the  specimen  and  stained  with  Loeffler's  alkaline  methyl-blue  solution, 
dried,  mounted,  and  examined.  The  diphtheria  bacilli,  if  present, 
do  not  resemble  closely  those  seen  in  cultures.  Here  or  there  one  or 
two  may  be  found  in  the  fibrin  and  detritus;  they  are  short  rods,  often 
swollen  slightly  at  one  or  both  ends.  Cocci  of  various  kinds  are  usually 
present.  If  the  bacilli  are  not  found  after  a  careful  search,  but  a  good 
many  cocci  are  seen,  it  is  fairly  good  evidence  that  the  disease  is  not 
true  diphtheria.  If,  on  the  other  hand,  bacilli  are  present,  it  cannot 
be  said  from  their  morphological  character  that  they  are  positively  of 
the  Loeffler  variety.  The  appearance  is  not  typical  and  the  staining 
qualities  are  subject  to  much  variation.  It  is  a  safe  rule  with  the  pres- 
ence of  membrane  to  regard  bacilli  in  a  direct  culture,  even  if  atypical, 
as  those  of  true  diphtheria,  if  there  l)e  occasion  for  immediate  treat- 
ment. 

In  taking  cultures  a  sterile  cotton  swab  is  applied  thoroughly  to  the 
affected  surface,  care  being  taken  to  ascertain  that  no  antiseptic  has  l)een 
used  fora  numberof  hours  previously.  In  suspected  laryngeal  diphtheria, 
without  apparent  pharyngeal  involvement,  it  is  advisable  to  aj)ply 
the  swab  if  possible  directly  to  the  interior  of  the  larynx.  The  mucus 
and  portions  of  membrane  thus  obtained  are  rubbed  gently  and  thor- 
oughly over  the  surface  of    a  tube  of  Loeffler's  blood  serum,  which 


DIPHTHERIA  4O5 

itself  has  been  rendered  sterile.  The  cotton  swab  is  then  removed, 
passed  through  the  flame,  or  returned  to  its  individual  tube  and  plugged 
with  absorbent  cotton.  The  culture  tube,  after  being  similarly  plugfyed, 
is  placed  for  twelve  hours  in  an  incubator  with  the  temperature  kept 
at  about  37°  C.  (99°  F.). 

For  the  examination  of  cultures,  a  sterile  platinum  loop  is  passed 
over  the  surface  of  the  culture  medium  so  as  to  remove  a  number 
of  colonies.  A  drop  of  sterile  water  is  placed  on  slide  or  cover-glass, 
the  bacterial  contents  of  the  loop  washed  off  in  it  and  smeared  over  the 
surface.  It  is  then  dried  in  the  air,  fixed  by  passing  it  throuo-h  the 
flame,  and  stained  from  five  to  ten  minutes  with  the  Loeffler  solution, 
washed  off  in  water,  dried,  mounted,  and  examined,  preferably  with 
an  oil-immersion  lens;  The  Neisser  stain  may  be  used  if  desired,  but 
it  is  doubtful  if  anything  more  may  be  learned  from  it  than  the  simpler 
methyl  blue. 

Cultures  which  show  pure  cocci  may  be  regarded  as  conclusive  evi- 
dence that  the  case  is  not  one  of  diphtheria.  When  the  bacilli  are  few 
in  number  and  are  atypical,  unless  the  clinical  evidence  points  strongly 
to  the  existence  of  diphtheria,  secondary  cultures  should  be  taken. 
Furthermore,  when  there  is  strong  clinical  evidence  of  diphtheria, 
especially  in  laryngeal  cases,  negative  cultures  should  be  disregarded 
in  the  presence  of  urgent  symptoms  and  specific  treatment  begun  at 
once. 

Prognosis. — No  disease,  unless  it  be  bronchopneumonia,  is  so  uncer- 
tain in  its  outcome  as  diphtheria,  and  in  each  case  a  number  of  factors 
have  to  be  considered  in  forming  a  prognosis.  Even  then  the  prac- 
titioner will  often  see  his  most  hopeful  cases  terminate  fatally,  and  the 
seemingly  most  hopeless  go  on  to  ultimate  recovery.  No  more  important 
element  enters  into  the  prognosis  than  that  of  the  patient's  age.  Chil- 
dren under  one  year  possess  a  certain  immunity  to  this  as  well  as  most 
other  infectious  diseases,  and  especially  nurslings  under  six  months. 
When  such  a  child  does  contract  the  disease  the  prognosis  is  not  favor- 
able. 

A  general  idea  of  the  mortality  according  to  age  is  afforded  by  the 
statistics  of  the  Boston  City  Hospital.  All  the  cases  were  treated  by 
antitoxin.  In  children  under  five  years  death  occurred  in  about  20 
per  cent,  of  the  cases,  in  those  from  five  to  ten  in  about  8  per  cent., 
and  from  ten  to  fifteen  3  per  cent. 

The  individual  constitution  of  the  patient  is  an  important  factor  in 
influencing  the  outcome  of  the  disease.  Those  who  are  anemic,  rachitic, 
the  subjects  of  lymphatic  hypertrophy  and  digestive  disturbances  show 
less  resistance  to  the  disease  than  those  previously  in  good  health. 

Institutional  and  tenement-house  cases  show  less  favorable  results 
than  those  taken  from  more  healthful  surroundings.  Pure  pharyngeal 
cases  may  be  considered  the  most  favorable,  with  the  exception,  perhaps, 
of  the  more  chronic  nasal  ones. 

Laryngeal  cases,  especially  when  operated  on,  justify  the  least  favor- 
able prognosis.     In  hospital  practice  the  death  rate  of  the  latter  has. 


40G  INFECTIOUS  DISEASES 

])\  the  use  of  antitoxin,  been  reduced  from  over  two-thirds  to  one- 
third  or  less.  In  private  practice  the  death  rate  is  much  lower.  The 
mortality  of  tracheotomized  cases  is  somewhat  higher  than  those 
intubated. 

Mixed  infections,  from  their  greater  liability  to  be  followed  by  com- 
plications, justify  a  less  favorable  prognosis  than  cases  of  pure  diph- 
theria. The  death  rate  in  cases  complicating  the  exanthemata  is  for 
this  reason  greater  than  in  primary  cases.  The  time  of  beginning  anti- 
toxin treatment  is  of  all  importance  in  forming  a  prognosis,  'rhus 
the  death  rate  varies  roughly  from  5  per  cent,  in  those  treated  in  the 
first  twenty-four  hours  to  35  or  more  in  those  in  which  it  has  been 
delayed  for  four  or  five  days.  In  other  words,  after  the  fourth  day,  tiie 
death  rate  approaches  that  of  pre-antitoxin  days.  The  cases  occurring 
in  the  winter  are  more  likely  to  be  followed  by  pulmonary  complica- 
tions than  those  of  the  summer  months.  In  general,  marked  toxemia, 
as  evidenced  by  restlessness,  stupor,  delirium,  rapid  and  irregular 
pulse,  paralysis,  and  kidney  involvement;  the  occurrence  of  j)neumonic 
lesions,  marked  involvement  of  the  lymph  nodes  and  i-a})id  spread  of 
the  membrane,  all  justify  an  unfavorable  prognosis. 

Diphtheria  affecting  other  mucous  membranes  than  those  of  the 
nose,  pharynx,  and  larynx,  as  well  as  that  occurring  on  abraded  cuta- 
neous surfaces,  rarely  terminates  fatally.  In  that  affecting  the  con- 
junctiva, when  properly  treated  at  an  early  stage,  the  prognosis  in 
regard  to  local  after-affect  and  loss  of  sight  is  ecjually  good. 

Prophylaxis. — Children  with  tendency  to  hypertrophy  of  lynipliatic 
tissue  of  the  nose  and  pharynx  should  be  especially  careful  to  avoid 
exposure,  and  these  conditions  should  receive  proper  attention.  All 
cases  of  diphtheria  should  be  isolated  as  perfectly  as  possible;  none 
other  than  the  nurse  or  member  of  the  family  acting  in  that  capacity 
and  the  physician  should  be  allowed  in  the  room,  the  doors  of  which 
should  be  kept  closed  as  much  as  possible.  A  large  vessel  (pail  to  be 
preferred)  partly  filled  with  a  carbolic  solution  of  a  strength  of  1  to 
20  should  be  kept  in  the  sick-room.  Articles  of  wear,  handkerchiefs, 
towels,  cotton  swabs,  etc.,  upon  which  discharges  from  the  nose  and 
mouth  have  been  caught,  should  be  soaked  in  this  solution  for  several 
hours,  after  which  they  may  be  removed,  boiled,  and  washed  in  the 
regular  way.  Bed-clothes  and  surfaces  soiled  by  discharges  should 
be  disinfected  immediately.  Utensils,  dishes,  cups,  etc.,  should  be 
kept  for  the  exclusive  use  of  the  patient  and  not  sent  from  the  sick- 
room. The  room  should  be  thoroughly  aired,  and  if  more  than  one 
can  be  utilized  the  patient  should  be  removed  once  a  day  while  the 
adjoining  room  is  swept  and  cleaned,  the  floor  being  previously  covered 
with  wet  paper  or  tea-leaves,  and  the  sweepings  afterward  burned  or 
disinfected.  All  unnecessary  furniture,  especially  of  the  upholstered 
variety,  should  be  removed  at  the  beginning  of  the  illness. 

The  patient  should  not  be  allowed  out  of  quarantine  until  cultures 
taken  from  the  site  of  the  lesion  no  longer  show  the  presence  of  Klebs- 
Loeffler  bacilli,  even  though  this  does  not  occur  for  several  weeks.    When 


DIPHTHERIA  407 

the  patient  is  ready  to  be  discharged,  he  or  she  should  be  given  a  thorough 
bath,  the  hair,  face,  and  body  thoroughly  washed  with  soap,  and  after- 
ward dressed  in  clean  clothes  which  have  not  been  exposed  to  con- 
tamination. \Mien  obliged  to  leave  the  sick-room,  the  nurse  should 
change  the  outer  clothes  or  remove  her  contagion  robe,  v/ash  the  hands, 
first  in  soap  and  water,  afterward  in  bichloride  of  mercury  solution 
of  the  strength  of  1 :  1000.  The  face  should  also  be  washed  in  a  weaker 
solution.  Nurses  who  consider  themselves  susceptible  should  receive 
immunizing  doses  of  antitoxin  during  their  attendance  on  diphtheria 
cases.  A  gargle  of  boric  acid,  listerine,  or  Dobell's  solution  may  be 
used  with  advantage  several  times  a  day.  The  physician  should  wear  a 
contagion  robe  before  entering  the  sick-room  and  leave  it  in  the  room 
on  his  departure.  It  should  completely  envelop  the  clothes,  the  neck, 
and  wrists.  In  addition  it  is  well  to  wear  a  cap  covering  the  hair  (see 
Fig.  90).  Before  leaving  the  house  the  hands,  face,  and  beard  should 
be  thoroughly  washed  in  a  disinfectant. 

^^  hen  the  patient  is  ready  to  be  dismissed  from  quarantine  the  room 
should  be  disinfected  as  follows :  The  walls  should  be  rubbed  down  with 
bread,  damp  cheese-cloth,  or,  when  possible,  washed  in  l)ichloride  of 
mercury  solution  1 :  ]  000.  The  woodwork,  furniture,  and  floor  should 
be  washed  with  the  same  solution.  Books,  toys,  etc.,  should  be  burned. 
Steam  disinfection  may  be  used  for  upholstery  of  all  kinds.  A  general 
disinfection  may  be  performed  by  the  use  of  formaldehyde  vapor,  pre- 
ferably under  pressure,  or  sulphur,  the  doors  and  windows  being 
previously  plugged  with  absorbent  cotton. 

For  the  prevention  of  diphtheria  in  those  who  have  been  exposed 
to  it  no  means  are  so  entirely  satisfactory  as  immunization  by  anti- 
toxin. The  immunity  conferred,  though  but  temporary,  three  weeks 
or  less,  nevertheless  gives  sufficient  time  for  the  original  course  of 
infection  to  disappear  and  thus  prevent  the  local  spread  of  the  dis- 
ease. This  is  especially  important  in  institutions  during  an  outbreak 
of  diphtheria,  and  also  during  epidemics  of  other  infectious  diseases, 
notably  measles,  upon  which  the  former  is  so  apt  to  be  engrafted.  Dur- 
ing measles  epidemic  in  children's  institutions  it  is  now  the  regular 
custom  to  give  immunizing  doses  of  500  units  to  all  the  children  affected. 
The  result  has  been  a  marked  decrease  in  the  death  rate  from 
diphtheria  complicating  measles.  The  following  taken  from  a  recent 
pamphlet  issued  by  the  Department  of  Health  of  New  York  City  speaks 
for  itself,  and  should  be  conclusive  proof  of  the  value  of  immunity  con- 
ferred by  antitoxin: 

From  January  1,  1895,  to  January  1,  1903,  immunizing  injections 
of  antitoxin  v/ere  administered  to  over  13,000  individuals  by  the  inspec- 
tors of  the  Department  of  Health,  and  by  physicians  Tfree  cases  only). 
Of  these  individuals  40  (0.3  per  cent.)  contracted  diphtheria  of  a  mild 
type;  one  case  only  terminated  fatally. 

The  records  of  the  Division  of  Bacteriologv  show  that  during;  one 
year  alone  682  cases  of  diphtheria  occurred  in  New  York  City,  which 
were  secondary  to  an  original  case  in  the  same  family.     Under  "Sec- 


408  INFECTIOUS  DISEASES 

ondary"  are  included  only  those  cases  which  occurred  at  least  twenty- 
four  hours  after  and  within  thirty  days  of  the  primary  case.  Of  these 
682  cases  61  died,  a  mortality  of  S.!)  per  cent.  Jlad  these  ()S2  individuals 
received  antitoxin  when  the  physician  first  visited  the  family,  probably 
not  one  of  them  woidd  have  contracted  the  disease.  The  above  figures 
represent  only  a  fraction  of  such  secondary  cases  occurring  in  New 
York  City. 

In  private  cases  it  should  be  routine  practice  to  give  immunizing 
doses  of  antitoxin  at  least  to  all  the  young  members  of  the  family  who 
have  been  exposed.  The  only  ill  effects  are  an  occasional  rash,  which 
causes  some  discomfort  and  a  slight  rise  in  temperature.  The  security 
ol)taine(l  more  than  repays  for  the  inexcusable  dread  which  some  per- 
sons exhibit  of  inoculating  a  healthy  person  for  any  purpose. 

Treatment. — -There  Ls  but  one  method  of  successfully  combating 
diphtheria  after  it  has  once  occurred,  now  recognized  by  practically  all 
physicians  throughout  the  civilized  world,  namely,  by  the  use  of  properly 
prepared  antitoxin  given  in  sufficient  dosage  and  as  early  as  possible 
in  the  course  of  the  disease.  Since  its  use  has  become  general,  one 
after  another  of  the  remedies  formerly  regarded  as  possessing  a  specific 
action  have  passed  into  disuse.  Certain  adjuvant  measures  are  still 
of  great  importance  in  order  to  promote  the  comfort  of  the  patient, 
preserve  the  strength  and  diminish  the  risk  of  complications,  and  to 
increase  the  chances  of  recovery  when  these  have  occurred.  The 
patient  should  be  put  in  bed  and  kept  there  during  the  entire  course 
of  the  disease.  The  room,  or  preferably  two  adjoining  rooms,  should 
be  sunny  and  always  well  aired.  Running  water  should  be  included 
if  possible.  Patients  having  complications,  especially  pneumonia 
and  septic  conditions,  should  on  no  account  be  treated  in  the  same 
room  as  one  whose  case  is  not  so  complicated.  This  rule  should  be, 
but  unfortunately  is  not,  applied  to  hospitals  as  well  as  to  private  patients. 
Easily  digested  food  should  be  given  at  two  or  three  hours'  intervals 
and  in  small  quantities,  though  there  is  but  little  danger  of  a  patient 
overeating,  ^lilk  and  the  various  beef  preparations  are  often  more 
readilv  managed  than  solid  food.  Semisolids  are  usually  well  taken, 
(ravage  maybe  used  in  young  children  in  intubated  cases,  and  in  those 
in  which  the  condition  of  the  throat  prevents  the  taking  of  food.  For 
this  purpose  the  child  should  be  wrapped  as  described  for  intubation 
(Fig.  83)  and  the  tube,  a  catheter  attached  to  a  glass  funnel,  passed 
through  the  nose  or  mouth  into  the  esophagus.  The  necessary  quantity 
of  milk  is  then  poured  in,  and  the  tube  before  withdrawal  pinched 
between  the  thumb  and  forefinger  to  prevent  the  last  few  drops  from 
entering  the  larynx  and  exciting  an  attack  of  coughing,  a  desirable  pre- 
caution in  intubated  cases. 

Rectal  feeding  may  be  used  as  a  temporary  expedient  when  food 
cannot  be  readily  swallowed  or  is  not  retained.  The  bowels  should  be 
kept  open,  preferably  l)y  enemata.  If  reduction  of  the  fever  is  necessary 
it  should  be  accomplished  by  sponges  or  packs  at  85°  to  95°  F. 

All  severe  cases  with  evidences  of  marked  toxemia,  and  especially 
those  with  sepsis,  require  constant  stimulation,  as  do  those  in  which 


DIPHTHERIA 


409 


the  heart  action  is  weak  and  irregular.  Whiskey  and  brandy  of  the 
best  quahty,  in  doses  of  0.60  c.c.  (10  drops)  or  more  every  two  hours  in 
15  c.c.  (half  an  ounce)  of  water,  may  be  given  to  a  child  of  a  year  for 
an  indefinite  time.  For  older  children  60  c.c.  (2  or  more  ounces)  may 
be  given  in  the  twenty-four  hours,  well  diluted.  Strychnine  in  doses  of 
0.00065  gm.  (gr.  y^)  every  two  hours  may  be  given  to  the  youngest 
child,  and  twice  as  much  to  one  three  years  or  over.  The  symptoms  of 
poisoning  should  be  carefully  watched  for.  Strychnine  may  be  given 
hypodermically  in  the  same  doses,  or  nitroglycerin  in  doses  of  0.00016 
to  0.00065  gm.  (gr.  j^  to  yft)'  depending  on  the  age  of  the  child, 
when  rapid  stimulation  is  called  for.  Other  cardiac  stimulants,  as 
digitalis,  may  be  indicated  in  certain  conditions  of  the  heart.  Their 
effect  is  more  lasting,  but  they  have  a  tendency  to  upset  the  stomach. 
Sedatives,  such  as  bromide  of  sodium,  are  often  required.  They  are  to 
be  used  when  the  child  is  restless  and  wearing  out  its  strength  by  toss- 
ing about,  and  when  there  is  evidence  of  cardiac  involvement,  in  which 

Fig.  83 


Method  of  wrapping  the  patient  for  operative  or  local  treatment  and  gavage. 


perfect  quiet  means  so  much  for  the  ultimate  recovery  of  the  patient. 
Sedatives  may  also  be  used  before  removing  the  tube  in  intubated 
cases,  and  the  cannula  in  tracheotomized  cases,  in  order  to  diminish 
the  probability  of  having  to  reinsert  it;  in  laryngeal  cases,  which  have 
had  antitoxin  for  the  purpose  of  overcoming  a  spasmodic  attack  of 
dyspnea,  sedatives  may  be  given,  intubation  put  off  as  long  as  possible, 
and  the  antitoxin  given  an  opportunity  to  accomplish  its  purpose. 

No  drug  is  so  certain  in  these  various  conditions  as  morphine  given 
hypodermically  in  doses  of  0.00324  to  0.0054  gm.  (gr.  -^  to  ^V? 
and  repeated  if  necessary  at  two-hour  intervals.  As  a  general  sedative 
when  a  rapid  effect  is  not  necessary,  Dover's  powder  in  doses  of  0.03 
to  0.06  gm.  (gr.  h  to  1)  or  more  repeated  is  of  good  service. 

Emetics  are  of  value  in  certain  conditions,  although  their  use  is 
much  more  limited  to-day  than  formerly.  They  may  be  used  to  clear 
the  throat  and  larynx  of  thick  mucus  and  membrane,  or  when  it  is  not 
possible  to  intubate  at  once  in  laryngeal  cases  requiring  the  operation. 


410  INFECTIOUS  DISEASES 

There  is  rarely  occasion  to  make  use  of  them  except  at  the  beginning 
of  the  (Hsease.  For  this  purpose  syrup  of  ipecac  in  full  dosage  is  the 
leiust  harmful  and  is  generally  effective.  Aji  a  means  of  making  a  difier- 
ential  diagnosis  between  a  case  of  catarrhal  croup  and  true  diphtheria 
an  emetic,  together  with  the  other  measures  for  the  treatment  of  this 
condition  already  described,  is  perfectly  justifiable.  The  stenosis  of 
true  croup  (juickly  returns,  while  the  catarrhal  condition  is  generally 
relieved,  at  least  for  many  hours. 

Local  Treatment. — At  the  present  time  local  treatment  with  the  object  of 
directly  ati'ecting  the(Hphtheritic  process  has  been  almost  universally  aban- 
doned, and  forcible  removal  of  membrane  and  the  applications  of  strong 
bactericidal  remedies  have  been  proved  to  be  not  only  useless,  but  in  nuuiy 
cases  actually  harmful.  A  cleansing  irrigation  with  mild,  bland  solutions 
for  the  purpose  of  removal  of  already  detached  membrane,  together  with 
thick  mucus  and  pus,  and  reducing  the  local  congestion  are  of  the 
greatest  value.  For  this  purpose  there  is  needed  an  ordinary  fountain 
syringe  holding  two  quarts,  or  irrigator  of  glass  or  agateware,  an  olive- 
tippcfl,  hard-rubber  or  glass  nozzle  for  use  in  the  nose,  and  a  longer 
hard-rubber  tip  for  use  in  the  throat.  A  solution  of  common  salt  of  the 
strength  of  4  gm.  to  0.6  litres  (a  teaspoonful  to  a  pint) ;  a  saturated 
solution  of  boric  acid,  or  one  of  the  ordinary  mouth  washes,  such  as 
listerine  well  diluted,  is  preferable  to  most  other  and  stronger  solutions. 
A  temperature  of  somewhat  over  100°  F.  for  ordinary  cases,  or  one  of 
12.5°  F.  or  more  with  the  object  of  reducing  congestion  is  to  be  used. 
The  receptacle  should  be  placed  four  or  five  feet  above  the  patient's 
head,  the  latter  wrapped  in  a  sheet  as  shown  in  the  illustration  (Fig.  84), 
over  which  is  pinned  a  rubber  blanket  closely  round  the  neck.  The 
patient  is  put  on  the  side  on  a  table,  its  head  lying  on  a  Kelly  pad,  which 
should  drain  into  a  solution  of  carbolic  acid.  The  head  is  held  firmly 
against  the  tal)le  with  the  left  hand.  The  nozzle  of  the  syringe  is  then 
placed  in  the  upper  nostril  and  a  small  amount  of  water  allowed  to  flow, 
after  which  it  is  momentarily  removed  and  the  patient  permitted  to 
take  a  breath  or  two  to  be  reassured.  The  irrigation  is  then  continued 
until  the  result  of  the  washing  is  a  perfectly  clear  fluid.  By  this  means 
large  nasal  plugs  of  fibrin  are  often  removed,  which  otherwise  would 
serve  to  obstruct  respiration  and  by  their  decomposition  serve  as  a  source 
of  infection  by  various  organisms.  For  the  irrigation  of  the  mouth, 
which  is  usually  performed,  when  necessary,  directly  after  that  of  the 
nose,  the  special  nozzle  is  passed  gently  between  the  cheek  and  the 
teeth,  the  water  allowed  to  flow,  and,  as  the  mouth  opens,  the  tip  of  the 
nozzle  is  gradually  passed  to  the  middle  line,  the  tonsils  and  pharynx 
being  in  this  way  cleansed  from  thick  mucus,  pus,  and  pieces  of  detached 
membrane. 

The  operation  may  be  repeated  every  four  hours  in  ordinary  cases 
and  every  two  hours  in  those  in  which  there  is  a  great  deal  of  nasal 
discharge,  especially  of  a  purulent  variety. 

While  there  is  a  difference  of  opinion  in  regard  to  the  propriety  of 
this  procedure  in  certain  cases,  I  believe  that  there  are  practically  no 


DIPHTHERIA 


411 


contraindications,  and  that  there  is  no  good  evidence  that  disease  of 
the  middle  ear  is  more  apt  to  follow  cases  which  are  irrigated  than  those 
which  are  not.  Furthermore,  there  is  no  good  reason  why  intubated 
cases  with  nasal  involvement  should  not  })e  so  treated,  and  while  the 
operation  occasionally  causes  an  attack  of  coughing,  which  may  result 
in  the  expulsion  of  the  tube,  the  latter  may  be  immediately  reinserted. 
'J'he  value  of  irrigation  in  such   cases  far  outweighs  the  inconvenience 


Fig.  84 


Irrigation  of  the  nose. 

of  this  occasional  occurrence.     Finally,  there  is  no  evidence  that  aspira- 
tion pneumonia  is  ever  caused  by  the  procedure. 

A  less  efficacious  method  of  cleansing  the  nose  and  tliroat  is  that  by 
means  of  an  ordinary  syringe  or  bulb  syringe.  Too  much  force  is  apt 
to  be  used,  it  is  less  agreeable  to  the  patient,  and  the  result  is  far  less 
satisfactory.  In  cases  of  cardiac  paralysis  great  care  should  be  taken 
to  avoid  exciting  the  patient,  but  as  this  condition  usually  occurs  late 
in  the  disease  the  indication  for  irrigation  is  not  often  present. 


412  INFECTIOUS  DISEASES 

Local  applications  for  the  relief  of  spasm  and  pain  and  reduction  of 
swellinij  are  oecasionallv  of  service.  Steam  inhalations  hy  means  of 
a  croup  kettle,  the  child  being  placed  under  a  canopy,  may  be  continued 
for  from  one-half  to  one  hour  at  a  time.  Hot,  thin,  flaxseed  poultices 
placed  on  the  throat,  and  immediately  removed  on  cooling, seem  to  afford 
relief  in  these  conditions.  The  steam,  however,  should  on  no  account 
be  kept  up  for  any  great  lengtli  of  time  to  the  exclusion  of  fresii  air,  and 
the  poultices  not  used  oftener  than  at  intervals  of  two  or  three  hours. 

In  conjunctival  diphtheria,  in  addition  to  the  use  of  full  doses  of  anti- 
toxin, the  treatment  should  in  general  be  that  of  a  purulent  conjunc- 
tivitis, namely,  ice-cloths  applied  every  few  mimites  to  rechice  the 
swelling  and  congestion,  mydriatics,  atropine  (or  cocaine),  constant 
separation  of  the  lids  and  washing  out  of  the  eyes  by  means  of  a  medicine 
dropper,  boric  acid  or  other  mild  solution,  and  the  application  of  a 
drop  or  two  of  nitrate  of  silver  solution  several  times  a  day. 

At  the  Boston  City  Hospital  the  use  of  the  red  or  yellow  iodide  of 
mercury  as  a  local  application  to  the  lids,  0.06  gm.  to  30.00  gm.  (1  grain 
to  1  ounce  vaselin),  is  l)elieved  to  have  been  of  benefit. 

Antitoxin. — In  1893  Hehring  may  be  said  to  have  established  the 
real  value  of  antitoxin  in  the  treatment  of  diphtheria.  Previous  to  this, 
he,  with  other  experimenters  had  made  tentative  trials  of  it,  but  in  an 
imperfect  manner.  It  is  not  remarkable  that  since  the  introduction  of 
this  specific  remedy  there  has  risen  opposition  to  its  use  from  time  to 
time.  This  has  rested  upon  reports  of  sudden  death  after  its  admin- 
istration, septicemia,  tetanus,  local  infection,  and  of  negative  results 
following  its  use.  It  is  undoubtedly  true  that  in  the  early  days  of  anti- 
toxin the  serum  was  not  always  what  it  should  have  been.  It  was  not 
sufficiently  concentrated,  nor  always  pure  or  properly  preserved.  "^Phe 
proper  dosage  was  not  definitely  known,  nor  were  the  limitations  to  its 
efficacy  appreciated.  It  is  not,  of  course,  possible  to  investigate  the 
truth  of  many  of  these  reported  mishaps,  but  it  may  be  set  down  as  an 
indisputable  fact,  deduced  from  hundreds  of  thousands  of  cases  in  which 
antitoxin  has  been  administered  and  its  effect  carefully  watched,  that  in 
nocase  has  death  l)een  caused  l)y  a  properly  prepared  pure,  fresh,  serum. 

Death  can  occur  and  has  occurred,  and  alarming  symyjtoms  have 
followed  an  infected  serum,  one  that  has  not  been  properly  preserved, 
and  one  injected  without  proper  antiseptic  precautions.  Sudden  death 
occurs  in  diphtheria  with  or  without  the  use  of  antitoxin;  that  it  should 
be  attributed  to  the  remedy  and  not  the  disease  in  a  certain  munber 
of  cases  is  not  difficult  to  understand.  There  is,  however,  no  such  good 
reason  for  the  l)elief  that  antitoxin  per  se  is  dangerous  to  life.  Certain 
symptoms,  however,  that  are  not  dangerous  to  life,  very  often  follow  its 
administration,  and  they  are  now  generally  recognized  and  will  be 
noted  later.  The  j)r()duction  of  antitoxin  should  l)e  under  strict  muni- 
cipal control  even  if  the  actual  manufacture  be  left  to  private  con- 
cerns, as  the  greatest  possible  care  is  essential. 

Efject  of  Serum  Treatment. — The  following  table  just  published  by 
the  Department  of  Health  of  Xcw  York  C^ity  may  be  taken  as  fairly 


DIPHTHERIA  4J3 

representative  of  the  effect  of  antitoxin  upon  the  general  mortahty  in 
a  large  number  of  cases.  These,  of  course,  include  hospital  cases  as 
well  as  those  treated  in  private  practice,  cases  dying  of  complications 
and  those  in  which  the  antitoxin  was  not  administered  until  very  late 
in  the  disease,  and,  in  not  a  small  number,  where  antitoxin  was  omitted 
for  various  reasons,  such  as  the  wish  of  the  parents  or  disbelief  in  its 
value  by  the  attending  physician. 

Table  Showing  Number  op  Cases,  Deaths,  and  Mortality  Per  Cent,  of 
Diphtheria  in  the  Boroughs  of  M.inhattan  and  The  Bronx,  from 
1893  TO  1904,  Inclusive: 

Period.  Cases.  Deaths.         Mortality  per  cent. 

1893 7,021  2558  36.4 

1894 9,641  2S70  29.7 

1S95 10,353  1976  19.1 

1896 11,399  1763  15.4 

1897 10,896  1590  14.6 

1898  .......  7,593  923  12.2 

1899 8,240  1087  13.1 

1900 8,364  1121  13.4 

1901  .   .       ....  7,726  1227  15.9 

1902 -  .    .  10,429  1142  10.9 

1903 11,662  1302  11.2 

1904 12,183  1272  9.57 

At  the  New  York  Foundling  Hospital  the  mortality  rate  from  all 
cases  of  diphtheria  complicated  and  uncomplicated,  primary  and 
secondary,  to  other  infectious  diseases,  operative  and  non-operative, 
is  9  per  cent,  in  300  cases. 

It  is  possible  for  many  physicians  to  make  a  far  better  showing  than 
the  above  in  cases  taken  from  their  private  practice. 

Probably  a  death  rate  of  4  or  5  per  cent,  will  fairly  represent  the 
results  of  uncomplicated  cases  treated  on  the  first  day.  While  the 
general  mortality  has  decreased  so  markedly  the  death  rate  among 
infants  is  still  very  high,  and  has  not  apparently  been  reduced  in  the 
same  proportions  as  that  among  older  children,  a  fact  which  is  due  not 
only  to  the  great  susceptibility  of  infants  to  the  specific  toxin,  but  to 
the  frequency  of  pulmonary  complications. 

Effect  upon  Laryngeal  Diphtheria. — In  these  cases  the  benefits  of 
antitoxin  may  be  seen  in  two  ways:  first,  by  reducing  greatly  the  number 
of  cases  which  require  operative  interference,  and  second,  by  reducing 
the  death  rate  in  operative  cases. 

The  great  extent  of  membrane  formerly  seen  in  the  larynx  and  trachea 
is  now  seldom  met  with. 

Furthermore,  the  time  during  which  a  tube  must  be  worn  continuously 
has  been  notably  decreased,  and  multiple  reintubations  are  less  fre- 
quentlv  required.  Before  the  days  of  antitox-in  nearly  every  case  of 
laryngeal  diphtheria  progressed  to  the  stage  where  operative  inter- 
ference was  necessary;  to-day  only  one-half  of  such  cases  require  it. 
Without  antitoxin  death  occurred  in  about  two-thirds  of  the  cases 
operated  on.  With  antitoxin  the  death  rate  is  less  than  one-third,  and 
it  is  possible  to  quote  a  number  of  physicians  who  have  had  a  dozen 


414  INFECTIOUS  DISEASES 

or  more  cases  in  private  practice  without  a  death.  The  statistics  in 
regard  to  tracheotomy  are  only  less  favorable  than  those  of  the  bloodless 
operation. 

Effect  on  the  Occurrence  of  Complications. — In  regard  to  the  nervous 
system  it  has  been  shown  experimentally  and  corroborated  clinically 
that  antitoxin  administered  at  the  time,  or  sliortly  after  the  diphtheritic 
toxin  had  become  active,  provided  it  is  given  in  doses  sufficient  to 
neutralize  the  latter,  regularly  prevents  the  occurrence  of  paralyses. 
So  sensitive  is  the  nervous  system  to  this  particular  poison  that  even  a 
delay  of  twenty-four  hours  greatly  adds  to  the  probability  of  occurrence 
of  nervous  symptoms,  and  after  the  second  day  the  effect  of  antitoxin 
in  this  regard  is  practically  negative. 

The  same  rule  applies  to  the  cardiac  symptoms  of  diplitheria.  Neph- 
ritis is  not  a  common  complication  of  pure  diphtheria.  It  has  been 
shown  that  it  is  less  Hkely  to  occur  with  the  use  of  antitoxin  than  without 
it.  Upon  the  occurrence  of  complications,  due  to  associated  organisms, 
such  as  the  streptococcus,  pneumococcus,  and  staphylococcus,  antitoxin 
has  a  real  but  indirect  effect  in  that  it  shortens  the  course  of  the  diph- 
theria and  restores  to  the  normal,  at  an  earlier  date,  the  affected  mucous 
membranes;  so  that  there  is  less  opportunity  for  the  production  of 
complicating  lesions  by  these  organisms,  and,  with  the  early  admin- 
istration of  antitoxin,  bronchopneumonia,  local  suppurative  conditions, 
and  general  sepsis  are  less  frequently  observed. 

When  diphtheria  is  implanted  upon  another  infection  in  which 
pyogenic  germs  play  an  important  part,  as  in  scarlet  fever  and  measles, 
the  benefit  of  diphtheria  antitoxin  is  greatly  reduced,  and  it  is  in  this 
class  of  cases  that  preventive  measures  are  of  so  much  importance. 
Children  suffering  from  one  of  these  diseases  and  exposed  to  diplitheria 
should  never  fail  to  receive  full  immunizing  doses  of  antitoxin  at  once. 

Administration. — There  are  practically  no  contraindications  to  the 
use  of  antitoxin  when  the  diagnosis  of  diphtheria  is  once  established. 
In  those  cases  which  have  existed  from  five  to  seven  days  or  more  when 
first  seen  by  the  physician,  it  may  be  questioned  whether  the  use  of 
antitoxin  is  called  for  in  view  of  the  fact  tliat  its  power  will  be  so  greatly 
diminished  by  the  delay  in  administering  it.  In  severe  late  cases  it 
should  always  be  given  even  if  it  be  regarded  as  a  last  resort. 

In  all  cases  of  diphtheria  in  children  under  two  years  of  age,  however 
mild  or  at  whatever  site  the  lesion;  in  all  croup  cases  suspected  to  be 
due  to  diphtheria,  and  in  all  doubtful  croup  cases;  in  every  case  in 
which  there  is  a  membrane,  with  evidence  of  toxemia,  unless  positively 
known  to  be  of  non-diphtheritic  origin,  in  all  suspicious  eye  cases,  anti- 
toxin in  full  doses  should  be  given  at  once  without  waiting  for  the  result 
of  culture,  and  without  placing  too  much  reliance  upon  the  direct  bacterio- 
logical finding  by  the  method  previously  described. 

In  mild  pharyngeal  cases  in  older  children;  in  membranous  pharyn- 
gitis or  tonsillitis  occurring  with  scarlet  fever  or  measles ;  in  chronic 
suspicious  nasal  cases;  in  anogenital  cases;  in  typical  follicular  tonsillitis; 
in  catarrhal  angina  which,  on  account  of  the  exposure  of  the  patient 


DIPHTHERIA  415 

to  diphtheria,  may  be  regarded  as  suspicious,  it  is  allowable  to  wait  for 
the  result  of  cultures,  in  the  absence  of  alarming  symptoms,  but  in 
every  case  of  doubt  when  such  symptoms  are  present,  antitoxin  should 
be  given  at  once.  Thus,  while  the  vast  majority  of  cases  of  membranous 
angina  which  occur  in  scarlet  fever  and  measles  are  due  to  pvogenic 
cocci  and  those  of  tonsillitis  with  a  typical  follicular  distribution  due  to 
the  same  organism,  yet  the  Klebs-LoefHer  bacillus  is  not  infrequently 
found  associated  wuth  them  under  these  conditions. 

Dosage. — In  ordinary  mild  cases  of  pharyngeal  or  nasal  diphtheria 
2000  to  4000  units  should  be  given.  In  severe  cases,  at  the  same  location, 
twice  as  much.  The  smaller  the  child  the  smaller  is  the  dose  required, 
but  it  is  better  to  give  too  much  than  too  little  in  any  case.  In  laryngeal 
cases  5000  to  10,000  units,  depending  not  so  much  on  the  symptoms  as 
on  the  age  of  the  patient,  should  be  given.  This  dosage  should  be 
repeated  in  twelve  hours  if  the  local  conditions  appear  less  favorable, 
and  in  laryngeal  cases  if  the  symptoms  of  stenosis  fail  to  show  an  ameli- 
oration. A  third  dose  is  sometimes  required.  It  is  very  doubtful  if 
the  huge  dosage  of  4000  to  50,000  units  or  more  has  produced  any  better 
results  than  in  those  of  the  size  just  enumerated.  For  purposes  of 
immunity  the  dose  should  be  from  500  to  1000  units,  depending  on  the 
age  of  the  child  and  on  the  probability  of  its  contracting  the  disease. 
In  eye  cases  5000  units  or  more  should  be  given.  Any  syringe  holding 
10  c.c.  which  can  be  boiled  may  be  used.  A  small  needle  is  preferable. 
The  skin  at  the  site  of  injection  should  be  cleaned  with  soap  and  water, 
alcohol,  and  bichloride  of  mercur}"  solution.  The  tissues  below  the 
scapulae  on  the  outside  of  the  thigh  or  buttocks  may  be  selected.  The 
serum  should  be  injected  deeply,  and,  after  \\dthdrawing  the  needle,  a 
piece  of  sterile  gauze  or  cotton  placed  over  the  wound  and  held  in  place 
by  a  piece  of  adhesive  plaster  or  collodion. 

Clinical  Effects  of  Aniiioxin. — A  few  hours  after  injection,  seen  most 
typically  in  cases  of  pure  diphtheria  of  the  tonsil,  the  membrane  begins 
toswell,  and  later  its  edges  become  loosened  from  the  underlying  mucous 
membrane  and  curl  up.  \er\  soon  it  detaches  itself  en  masse,  or,  more 
often,  in  small  pieces.  The  detachment  takes  place  in  from  twenty-four 
hours  to  four  days.  In  nasal  cases  membranous  casts  of  the  nares  are 
loosened  and  come  away  in  the  irrigation  fluid.  In  eye  cases,  especially 
those  in  which  there  is  not  mixed  infection,  the  process  is  seen  in  its 
typical  form  and  similar  to  that  of  the  tonsils.  In  laryngeal  cases,  if 
the  case  progresses  favora])ly,  after  a  few  hours  the  stenotic  symptoms 
gradually  disappear.  If,  on  the  other  hand,  the  case  goes  on  to  iritu- 
bation,  and  there  is  an  appreciable  amount  of  membrane  present,  the 
latter  is  either  coughed  up  through  the  tube  or  may  obstruct  its  lumen  and 
causes  autoextubation  or  removal  of  the  tube.  The  moderate  involve- 
ment of  the  lymph  nodes  of  the  neck  seen  in  pure  diphtheria  rapidly 
subsides,  the  temperature  and  pulse  decrease,  and  the  toxemia  soon 
disappears. 

In  mixed  cases  all  these  phenomena  follow  the  use  of  antitoxin,  but 
are  less  well  marked.     Thus  the  temperature  and  pulse  rate  may  remain 


416  INFECTIOUS  DISEASES 

high  and  the  general  condition  of  the  patient  not  show  the  same  improve- 
ment as  in  cases  of  pure  diphtheria. 

Effect  on  the  Blood. — As  shown  by  Ewing  and  others,  antitoxin  has 
the  effect  of  decreasing  the  hyperleukocytosis  caused  by  (Hphtheria. 
When  this  \vds  not  occurred  the  (Hsease  h.is  often  terminated  fatally. 
Other  observers  have  noticed  a  diminution  of  hemoglobin  and  red  blood 
cells  following  the  injection. 

Effect  of  Horse  ISerum. — Certain  clinical  manifestations  very  regularly 
follow  the  injection  of  antitoxin.  These  are  now  recognized  as  being  due 
wholly  to  horse  serum  and  not  to  the  antitoxin  itself;  for  they  have  been 
shown  to  follow  the  injection  of  the  former  when  in  its  natural  state. 
The  fre(juency  of  their  occurrence  as  well  as  the  severity  of  the  symp- 
toms depends  to  a  great  extent  on  the  amount  of  serum  injected,  but 
it  is  also  found  that  that  of  certain  horses  much  more  regularly  {)roduce 
them  than  others,  and  they  are  for  that  reason  usually  discarded,  'i'he 
greater  concentration  of  the  antitoxin  has  greatly  diminished  the  number 
of  cases  in  which  these  manifestations  occur.^  Tli<-T  ^^^  never  dangerous 
to  life,  but  are  frequently  the  source  of  grave  discomfort  to  the  patient 
for  the  time  being,  and,  therefore,  to  be  avoided  if  possible.  Various 
skin  eruptions  follow  the  injection  of  antitoxin  in  from  10  to  25  j)er  cent, 
of  the  cases.  They  occur  from  the  second  day  to  the  third  week  or  even 
later.  The  eruption  may  be  confined  to  the  site  of  inoculation  or  it  may 
cover  more  or  less  of  the  face  and  body.  In  any  event,  the  point  of 
inoculation  is  usually  the  starting  point.  The  most  frequently  observed 
eruption  is  a  general  erythema;  the  next  most  common  an  urticaria, 
frequently  seen  in  connection  with  the  former.  Others  less  connnon 
are  scarlatiniform  and  morbilliform.  IMixed  varieties  are  frequently 
observed.  The  scarlatiniform  and  morbilliform  rashes  regularly  occur 
at  a  later  stage  than  the  others.  The  duration  of  these  various  eruptions 
varies  from  a  few  hours  to  a  day  or  two.  They  not  infrecjuently  dis- 
appear and  return  again.  There  is  regularly  a  rise  in  temperature  and 
pulse,  an  intense  itching,  and  irritability  of  the  skin ;  in  some  cases  the 
eyes  and  face  are  intensely  swollen ;  less  often  intense  pain  in  the  joints 
is  observed,  occasionally  with  swelling  and  redness.  The  fever  reaches 
its  height  with  the  full  development  of  the  eruption  and  then  rapidly 
subsides.  The  diagnosis  of  the  scarlatiniform  variety  is  often  difficult 
as  it  very  closely  resembles  true  scarlet  fever.  The  points  on  which  it  is 
based  are  the  starting  point  of  the  rash  from  the  point  of  inoculation, 
its  very  rapid  and  more  general  distribution,  its  evanescent  character, 
and,  very  often,  the  lack  of  uniformity  of  the  eruption;  other  varieties, 
such  as  urticaria,  occurring  in  other  parts  of  the  body.  In  cases  of  doubt 
the  patient  should  be  isolated. 

1  The  Health  Department  of  New  York  is  now  supplying  a  purified  and  concentrated  diphtheria 
antitoxin.  This  product  is  extremely  reliable  and  is  not  apt  to  produce  rashes  and  other  deleterious 
efiects  as  the  ordinary  serum. 


DIPHTHERIA 


4.VJ 


INTUBATION. 

Intubation  for  the  relief  of  acute  laryngeal  stenosis  was  perfected 
after  three  years  of  experimentation  by  Dr.  Joseph  0'D^\^er,  of  New 
York,  in  1883.  This  operation  has  almost  entirely  superseded  that  of 
tracheotomy  in  America  and  on  the  continent  of  Europe.  In  England 
the  older  operation  is  still  frequently  performed. 

Intubation  Instruments. — The  present  tubes  are  made  of  vulcanized 
rubber  on  a  metal  frame,  in  six  or  more  sizes  corresponding  to  the  age 
of  the  child.  '\'Mien  in  position  they  reach  nearly  to  the  bifurcation  of 
the  trachea.  The  retaining  swell  is  of  such  a  calibre  that  the  cricoid 
constriction  of  the  larynx  keeps  the  tube  in  place  under  ordinary  circum- 
stances and  yet  allows  of  its  ready  expulsion  when  the  lumen  is  blocked 


Fig.  85 


Fig.  86 


O'DwTer's  intubation  tubes. 


by  loose  membrane.  The  neck  is  made  as  narrow  as  possible  and  is 
gripped  by  the  vocal  cords.  In  order  to  avoid  ulceration  of  the  mucous 
membrane  by  pressure  the  head  of  the  tube  has  been  given  a  backward 
sweep  and  is  somewhat  thick,  so  that  no  sharp  angle  is  presented  to  the 
base  of  the  epiglottis.  The  end  of  the  tube  is  blunt  and  well  rounded 
off  to  prevent  ulceration  by  the  movement  of  the  trachea  over  this  part. 
Furthermore,  it  is  advisable  to  use  the  smallest  possible  tube  for  the  age 
of  the  child  to  diminish  pressure  at  the  cricoid  constriction. 

The  general  character  of  the  tubes  and  instruments  is  shown  in 
the  illustrations  (Figs.  85  to  89). 

The  tubes  for  false  membrane  are  hollow  cylinders  in  graded  sizes 
of  just  sufficient  length  to  reach  beyond  the  cricoid  constriction  and 
are  for  temporary  use  only  to  allow  the  expulsion  of  the  detached  mem- 
brane when  this  is  suspected  to  be  present.  They  should  on  no  account 
27 


418 


INFECTIOUS  DISEASES 

Fu;.  S7 


O'Dwyer's  intubation  set  in  case. 


DIPHTHERIA 


419 


be  left  in  position  for  longer  than  an  hour  or  two,  as,  unlike  the  regular 
tubes,  they  are  not  adapted  to  the  anatomy  of  the  larynx. 

Special  tubes  with  built-up  heads  are  occasionally  used  with  the 
object  of  riding  over  the  granulations  caused  by  the  disease  and  thus 
promoting  their  absorption. 


Fig.  90 


Intubation  in  the  upright  position.    The  left  forefinger  is  on  the  epiglottis.    The  handle  of  the 
introducer  is  exactly  parallel  to  the  body.    The  tube  is  at  the  entrance  to  the  larynx. 

Many  modifications  of  O'Dwyer's  tubes  have  been  placed  on  the 
market.  None  of  them  possesses  any  advantage  over  the  original  model 
made  by  a  faithful  manufacturer,  who  worked  under  O'Dwyer's  personal 
supervision,  and  most  of  the  modifications  are  unfit  for  use. 


420 


IXFECTIO  US   DISK  A  SES 


The  short  tubes  of  Biiyeux,  whieh  are  so  eonstrueted  that  tliey  may  be 
pushed  from  the  larynx  by  pressure  on  the  traehea  (enucleated),  thus 
avoidiiifi;  tlie  use  of  the  extractor,  have  obtained  a  certain  vogue  in 
France  and  other  European  countries,  but  have  not  been  adopted  in 
tills  country. 

Indications  for  Intubation. — A  patient  with  laryngeal  diphtheria,  having 
l)een  given  antitoxin,  how^ever  great  the  probability  that  the  operation 
will  be  ultimately  required,  should  never  be  intubated  until  absolutely 
necessary.  When,  however,  there  is  cyanosis,  difficult  breathing,  marked 
retraction    about     the    epigastrium    and    clavicles,    and    auscultatory 


FicOl 


Intubation  in  reclining  position.    First  stage  of  ttie  operation. 

evidence  that  the  air  is  not  entering  freely  the  bases  of  the  lungs;  when 
the  pulse  is  weak  and  irregular,  the  patient  restless  and  evidently  being 
worn  out,  the  operation  should  no  longer  be  delayed. 

Method  of  Performing  Intubation. — The  operation  may  l)e  performed 
with  the  patient  in  the  upright  position  or  reclining;  the  latter  possesses 
the  advantage  of  absolutely  recjuiring  but  one  assistant,  and  even  that 
one  may  be  dispensed  with  in  an  emergency.  It  is  less  frequently 
employed  tlian  the  u})right  position.  In  either  ca.se  the  patient  should 
be  pinned  tightly  from  the  level  of  the  shoulders  to  the  feet  in  a  sheet 
or  blanket,    the    arms    being    confined    to    the    sides  (Fig.  91).    The 


DIPHTHERIA  421 

chest  should  be  left  bare.  If  the  operation  is  to  be  performed  in  the 
upright  position,  the  nurse  or  assistant,  sitting  upright  in  a  straight- 
backed  chair,  holds  the  patient  against  the  left  breast  by  crossing  the 
arms  in  front  of  the  body.  The  legs  of  the  patient  are  gripped  between 
the  nurse's  knees.  The  second  assistant  grasps  the  patient's  head 
firmly  between  her  hands,  the  thumbs  on  the  occiput,  the  little  finger, 
and.  perhaps,  the  fourth  finger,  being  placed  under  the  ramus  of  the  jaw 
to  pull  it  upward  so  that  the  neck  is  slightly  extended  (Fig.  90). 

When  intubating  in  the  reclining  position  the  patient  is  laid  on  its 
back  upon  a  table,  the  head  extending  beyond  it.  The  assistant  should 
hold  the  head  in  the  way  just  indicated  for  the  upright  position.  It  is 
sometimes  advisable  for  a  second  assistant  to  keep  the  child  from 
moving  about  by  holding  the  lower  extremities.  The  proper  tube  having 
been  selected  and  tested  to  see  that  it  slips  readily  from  the  obturator, 
and  its  eye  is  threaded,  preferably  by  a  strand  of  braided  silk,  the  mouth 
gag  is  introduced  between  the  back  teeth  on  the  left  side  and  opened 
widely,  the  handles  of  the  gag  being  included  between  the  left  hand 
of  the  nurse  and  the  patient's  cheek  (Fig.  91).  In  younger  children 
without  back  teeth,  it  is  well  to  pad  the  jaws  of  the  gag  or  dispense 
with  it  altogether  in  order  to  avoid  wounding  the  gums. 

The  operator  then  inserts  his  left  index  finger  into  the  patient's  mouth, 
finds  the  epiglottis  and  drags  it  directly  forward ;  at  the  same  time 
crowding  his  finger  as  much  as  possible  to  the  left  he  passes  the  tube 
directly  in  the  middle  line,  and  hugging  the  tongue  as  closely  as  possible 
under  the  edge  of  the  finger-tip  until  the  tube  engages  in  the  rim  of  the 
glottis.  At  the  beginning  of  the  operation,  whether  the  patient  is 
upright  or  reclining,  the  handle  of  the  introducer  should  be  parallel  to 
the  body  of  the  child.  As  the  tube  approaches  the  glottis  the  handle  is 
gradually  raised  until,  as  it  engages  between  the  vocal  cords,  the  intro- 
ducer passes  beyond  the  perpendicular  to  the  child's  body.  The  tube 
then  pointing  directly  down  the  trachea,  is  passed  gently  between 
the  vocal  cords  to  a  distance  of  about  two-thirds  of  its  length,  when 
the  left  forefinger  should  be  removed  from  the  epiglottis  and  placed 
on  the  side  of  the  head  of  the  tube,  pushing  the  latter  into  place  and 
holding  it  there  at  the  same  time  that  the  obturator  is  released  by 
means  of  the  right  thumb  and  withdrawn  quickly  by  a  slightly  lifting 
and  rotary  movement  from  the  mouth.  The  gag  is  then  removed.  If 
the  tube  is  properly  placed  in  the  trachea  there  will  be  a  succession  of 
hollow  coughs,  together  with  the  expulsion  of  more  or  less  mucus  and 
blood.  The  symptoms  of  stenosis  are  immediately  relieved,  cyanosis 
disappears,  and  the  child,  already  exhausted,  lies  contented  and  very 
often  sleeps.  The  cord  should  be  left  in  for  a  few  minutes  so  that  the 
tube  may  be  removed  quickly  in  case  of  possible  obstruction.  In  young 
children,  and  in  older  ones,  if  so  desired,  it  may  be  left  indefinitely,  but 
under  ordinary  circumstances  it  is  better  to  remove  it,  as  it  is  often  a 
source  of  annoyance  and  is  frequently  bitten  off.  For  its  removal  it  is 
only  necessary  to  cut  one  end  at  the  corner  of  the  mouth,  and,  without 
inserting  the  gag,  quickly  place  the  left  forefinger  on  the  tube  and  pull 


422 


INFECTIOUS  DISEASES 


it  out.  If  the  strin<]j  is  to  be  retained  it  should  l)e  fastened  by  means 
of  u  strip  of  adhesive  phister  to  the  left  cheek. 

Tn  order  to  perform  the  operation  successfully  the  following;  ])oints 
should  be  emj)hasix,ed :  See  that  the  child  is  lu^ld  ])roperly  and  is 
immovable,  and  that  the  pro])er  tube  has  l)(>en  selected  and  slips  freely 
from  the  obturator  when  releas(>(l.  The  introducers  should  be  held 
between  the  thumb  and  finovrs  and  never  f^rasped  (irmly,  th(>  tnl)e 
should  be  introduced  as  nearly  as  possible  in  the  middle  line,  and  hnally 
tiie  left  forefiiifjjer  should  never  leave  the  e])iol()t(is  until  the  tube  has 
becMi  well  introduced  into  the  larynx.  In  difhcult  cases  several  short 
ert'orts  at  introduction  are  far  ym'ferable  to  ])rolonoed  attem])ts. 

Extubation. — In  this  operation  the  ])osition  of  the  patient  is  exactly 
the  same  as  that  required  for  intubation;  the  left  forefinger  is  either 
placed  on  the  epiglottis,  serving  as  a  guide  for  the  beak  of  the  extractor, 
or  |)referal)ly  on  tlie  arytenoid  cartilages,  the  beak  of  the  extractor  being 
then  passed  along  the  middle  line  of  the  ])ulp  of  the  finger,  and  l)y  the 
quick  elevation  of  the  handle  it  glides  into  the  o])ei!ing  of  the  tub<>.  In 
order  to  avoid  laceration  of  the  tissues  by  premature  opening  of  the  jaws 
of  the  extractor,  the  thumb  should  not  be  put  on  the  spring  until  the 
closed  beak  is  well  within  the  larynx.  The  s])ring  is  th(>n  ])r<'ssed  on 
hrmlv  and  continuously,  the  tube  removed  from  the  larynx  by  a  com- 
bined lifting  and  rotary  movement  (Fig.  91). 


Fig.  92 


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TempcTature  chart.    Intubation  and  extubation  in  laryngeal  diphtheria. 


When  to  Extx  bate. — The  time  during  which  it  is  necessary  to  leave 
the  tube  in  position  depends  on  the  severity  of  the  case,  the  general  con- 
dition of  the  patient,  and  the  evidences  of  toxemia.  The  younger  the 
child,  the  longer  the  time  required  for  the  retention  of  the  tube.  For 
children  over  two  years  of  age  it  is  usually  customary  to  remove  the 
tube  on  the  third  day.  In  many  eases  reintubation  will  be  necessary, 
though  with  the  use  of  antitoxin  this  is  much  less  often  necessary  than 
formerly.  When  there  is  evidence  of  obstructed  breathing  with  the 
tube  in  place  it  should  always  be  removed  immediately,  as  it  not  infre- 


DIPHTHERIA  423 

quently  happens  that  its  lumen  is  blocked  by  thick  mucus  or  membrane, 
although  under  these  circumstances  autoextubation  usually  occurs. 

Difficulties  of  the  Operatiox. — Xo  physician  should  undertake  to 
perform  this  operation  without  thorough  training  on  the  cadaver.  In 
unskilful  hands  the  child  may  be  killed  by  prolonged  attempts  to  intro- 
duce the  tube.  The  soft  parts  may  be  lacerated,  with  subsequent  infection 
and  false  passages  made,  especially  through  the  ventricles  of  the 
lar}Tix. 

It  occasionally  happens  that  membrane  is  pushed  down  before  the 
entering  tube,  in  consequence  of  which  the  symptoms  of  stenosis  instead 
of  being  relieved  are  increased,  the  patient  presenting  all  the  symptoms 
of  sudden  asphyxia.  The  tube  should  be  immediately  withdrawn,  the 
loose  membrane  usually  being  promptly  expelled ;  after  which  the  tube 
may  be  reintroduced.  That  this  accident  is  not  common  is  shown  by 
the  fact  that  it  has  seldom  or  never  occurred  in  a  long  series  of  intu- 
bations performed  by  skilled  operators,  and  there  can  be  no  doubt  that 
this  condition  has  often  been  held  responsible  for  the  accidents  due  to 
lack  of  skill  above  enumerated.  Subglottic  stenosis,  or  edema  of  the 
glottis,  occasionally  causes  some  difficulty  in  introducing  the  tube,  and 
is  the  only  occasion  in  which  a  certain  degree  of  force  is  necessary  in 
performing  the  operation. 

Retained  Tube. — Frecjuent  reintubations  are  due  to  ulcerations 
within  the  larynx,  with  more  or  less  destruction  of  the  cartilage,  cicatrices, 
granulations  and  paralyses  of  the  intrinsic  muscle.  These  conditions 
much  more  frequently  follow  cases  of  mixed  infection,  the  use  of  im- 
properly constructed  tubes  and  unskilfully  performed  operations. 

Feeding  of  Intubated  Cases. — The  method  of  feeding  by  gavage 
has  already  been  described  (p.  408).  In  infants  and  young  children  this 
maybe  kept  up  throughout  the  period  of  intubation. 

Casselberry's  position  may  be  employed  with  the  child  lying  across 
the  nurse's  lap,  the  head  slightly  back  and  feet  elevated  on  a  chair,  and 
the  food  given  wnth  a  spoon  or  from  a  bottle.  With  older  children  very 
little  difficulty  is  usually  experienced  in  feeding  after  the  first  day  or 
two.  They  are  quickly  taught  to  take  their  food  in  a  natural  position 
and  without  exciting  more  than  an  occasional  mild  attack  of  couo-hing. 
The  food  should  be  given  slowly  in  small  quantities,  semisolids  often 
being  more  readily  managed  than  liquids. 


TRACHEOTOMY. 

For  the  performance  of  this  operation  an  anesthetic  should  be  given 
when  possible.  The  patient  should  be  placed  on  a  table  under  a  good 
light,  the  head  well  back  and  steadied  by  an  assistant;  the  index  finger  of 
the  left  hand  should  be  used  to  locate  the  cricoid  cartilage,  the  larynx 
held  firmly  in  the  median  line  by  the  thumb  and  remaining  fingers.  An 
incision  is  then  made  exactly  in  the  middle  line  from  the  cricoid  down- 
ward for  a  distance  of  about  3  cm.,  the  skin  and  subcutaneous  tissues 


424 


INFECTIOUS  DISEASES 


being  divided.  The  left  forefinger  is  then  placed  over  the  bare  trachea 
at  the  upper  angle  of  the  wound,  and  by  means  of  a  bistoury  an  incision 
made  large  enough  to  admit  the  finger-tip,  after  which  the  canula  is 
introduced  in  the  tracheal  opening,  the  finger  being  withdrawn.  A 
tracheal  dilator  may  be  employed  in.stead  of  the  finger.  When  canular 
breathing  is  established  the  tube  is  fastened  in  place  by  means  of  a 
tape  about  the  neck,  a  strip  of  antiseptic  gauze  placed  about  the  wound 
and  over  the  opening  of  the  canula.  It  is  unnecessary  to  state  that 
every  antiseptic  precaution  should  be  taken  before  performing  this 
operation  except  in  emergency  cases  (Fig.  93). 


Flfi.  93 


Showing  correct  position  for  performing  tracheotomy. 


Among  the  accidents  which  may  happen  during  and  after  the  operation 
are  difficulty  in  introducing  the  camda  on  account  of  a  too  small  tracheal 
incision,  or  because  the  trachea  has  not  been  opened,  a  false  passage 
being  made  with  the  canula.  Hemorrhage  at  the  time  of  the  operation 
is  usually  not  severe  unless  the  incision  has  been  carried  too  low.  Sec- 
ondary hemorrhage  occasionally  occurs. 

Effects  of  the  Operation. — The  immediate  effects  of  introducing  the 
canula  are  exactly  similar  to  those  following  intubation.  There  is, 
lunvever,  more  apt  to  be  a  rise  in  temperature  lasting  for  a  day  or  two. 

Complications. — Infection  of  the  tracheal  wound  is  apt  to  follow 
emergency  operations   and   in   those   in   which   proper  antiseptic  pre- 


DIPHTHERIA  425 

cautions  have  not  been  taken.  Diphtheria  of  the  wound  occasionally 
occurs  and  sometimes  erysipelas.  Extensive  suppuration  with  sloughing 
of  the  tissues  and  occasionally  gangrene  are  sometimes  seen.  As  in 
intubated  cases  the  most  frequent  and  dreaded  complication  is  that  of 
bronchopneumonia. 

Treatment  of  Tracheotomized  Cases. — The  internal  canula  should  be 
removed  and  cleaned  at  first  at  intervals  of  two  or  three  hours,  and 
always  when  there  is  sign  of  obstruction.  The  external  canula  should 
be  removed  every  day  and  thoroughly  cleaned,  together  with  the  wound. 
After  the  second  or  third  day,  if  there  are  no  further  signs  of  laryngeal 
obstruction,  the  canula  may  be  removed  permanently  and  the  wound 
carefully  dressed.  Healing  usually  takes  place  rapidly.  To  prevent 
the  recurrence  of  laryngeal  stenosis  the  same  general  treatment  is 
indicated  as  that  advised  for  intubated  cases. 

Indications  for  Tracheotomy. — ^Tracheotomy  is  not  the  operation  of 
election  in  this  country.  It  should  be  performed  when  for  any  reason 
intubation  is  not  possible,  and  as  a  secondary  operation  when,  intubation 
having  failed  to  give  relief,  there  is  reason  to  suppose  that  the  obstruction 
is  due  to  tracheal  membrane.  Lastly,  in  some  cases  autoextubation 
recurs  so  constantly  that  larger  and  larger  tubes  have  to  be  used  in 
rapid  succession  and  the  integrity  of  the  larynx  is  endangered.  Here, 
again,  tracheotomy  may  be  resorted  to.  It  may  be  mentioned  that  at 
the  New  York  Foundling  Hospital  with  a  very  large  number  of  laryngeal 
cases,  occurring  both  before  and  since  the  introduction  of  antitoxin, 
tracheotomy  has  never  been  called  for  or  performed,  possibly  due  to 
the  fact  that  intubation  has  been  performed  by  members  of  the  staff 
who  have  been  thoroughly  trained  in  the  operation.  At  other  hospitals, 
where  the  patients  very  often  have  been  intubated  before  admission,  and 
with  variable  skill,  secondary  tracheotomy  is  not  infrequently  required. 


PSEUDODIPHTHERIA. 

Pseudomembranous  inflammations  due  to  other  than  the  diphtheria 
bacilli,  generally  the  pyogenic  cocci,  occur  in  by  far  the  greater  number 
of  cases  in  scarlet  fever,  measles,  and,  less  often,  influenza  and  exanthem- 
ata other  than  those  named.  They  may  be  regarded  as  a  local  evidence 
of  the  mixed  infections  so  likely  to  take  place  in  these  diseases.  Their 
presence  adds  to  the  danger  of  the  primary  disease  in  that  they  render 
probable  the  occurrence  of  local  suppurative  conditions  and  in  their 
worst  form  of  general  sepsis.  The  symptoms  of  this  condition  are 
masked  by  those  of  the  primary  disease. 

Primary  pseudodiphtheria  is  not  an  uncommon  condition,  especially 
in  institutions.  In  the  mild  and  most  frequent  form  the  membrane  is 
usually  confined  to  the  tonsils,  frequently  in  the  form  of  a  small,  grayish- 
white  patch  sunken  beneath  the  surface  of  the  tonsil.  The  latter  is  red 
and  swollen.  There  is  a  rapid  and  marked  rise  in  temperature  and  in 
the  pulse  rate  and  the  patient  very  often  feels  acutely  sick.    The  cervical 


420 


INFECTIOUS  DISEASES 


lymph  nodes  are  more  or  less  involved.  The  attack  lasts  a  number  of 
ilavs  and,  as  a  rule,  is  not  followed  hyeoniplications,  although  suppura- 
tion of  the  nodes  and  middle-ear  disea.se  may  oeeur.  In  the  severe  c-ases 
the  membrane  spreads  rapidly  and  is  apt  to  involve  the  pharynx  and 
nose.  There  may  be  sloughiufj  of  the  tissues  of  the  throat,  with  a  foul 
disehartre  from  mo\ith  and  nostrils,  irrcat  swelliuf^  of  the  lymph  nodes, 
verv  often  followed  bysuppuration.  ]Middle-ear  disease  is  very  frecjueut, 
bronchopneumonia  and  <j;eneral  sepsis  are  apt  to  oeeur  and  terminate 
the  disease  fatally.  In  the  severe  cases  the  larynx  also  may  be  involved 
with  svmptoms  of  larynijeal  stenosis  not  to  be  distinguished  from  that 
of  true  diphtheria.     This  occurrence,  however,  is  very  rare,  and  even 


Fig.  04 


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Temperature  chart.    Case  of  pseudodiphtheria,  \rith  recovery. 


if  the  larynx  be  involved  it  is  doubtful  if  in  such  cases  a  true  laryngeal 
membrane  is  present.  Cases  of  primary  streptococcus  croup  are  occa- 
sionally described.  The  diagnosis  of  such  a  condition  is  based  upon  the 
fact  that  one  or  more  cultures  taken  from  the  throat  fail  to  show  the 
presence  of  Klebs-Loeffler  bacillus,  but,  as  already  pointed  out,  this  is 
a  not  infrecpient  occurrence  in  cases  which  subsequently  show  the 
diphtheria  bacilli  in  great  numbers  at  a  later  stage  of  the  disease.  In 
my  opinion  such  cases  should  always  be  looked  upon  with  suspicion,  and 
even  if  their  occasional  occurrence  be  admitted,  they  are  excessively 
rare.  The  symptoms  are  those  that  have  been  described  and  are  exactly 
similar  to  cases  of  true  laryngeal  diphtheria  and  need  not  here  be 
dwelt  upon  (Fig.  94). 


CHAPTER    XVII. 

TYPHOID   FE^^R— MALARIA— EPIDEMIC  CEREBROSPINAL  IMENIN- 
GITIS— IX  FLUENZA. 

TYPHOID  FEVER. 

By  ISAAC  A.  ABT,  M.D. 

Etiology. — Typhoid  fever  is  due  to  the  presence  in  the  body  of  the 
typhoid  bacillus.  This  organism,  so  far  as  is  kno\\Ti  at  the  present 
time,  is  pathogenic  only  for  man.  The  bacillus  thrives  best  at  the 
temperature  of  the  human  body,  but  will  grow  to  some  extent  at  lower 
temperatures.  It  is  readilv  killed  by  heating  to  70°  C.  (150°  F.)  and  by 
antiseptics  (Figs.  95  and  96). 

Fig.  95 


Typboid  fever  bacilli.    One-twelfth  oil-immersion  lens. 


Most  frequently  typhoid  fever  is  contracted  by  infected  drinking- 
water,  and  next  by  infected  milk.  In  cities  where  the  water  supply 
is  contaminated  by  sewage  the  disease  is  always  prevalent.  ^Miere  the 
source  of  water  is' kept  free  from  pollution,  typhoid  becomes  compara- 
tively rare.  In  certain  cities  of  Europe  in  which  especial  precautions 
have  been  taken  to  obtain  a  pure  water  supply,  typhoid  fever  is 
practicallv  unknowTi. 

Milk  mav  be  infected  by  being  adulterated  with  water  which  contains 
typhoid  bacilli,  or  by  washing  cans  with  contaminated  water.     Wells  in 

(  427  ) 


428  INFECTIOUS  DISEASES 

the  country  are  frequently  infected  from  cases  of  typhoid  fever  in  the 
dairyman's  family.  The  udders  of  cows,  too,  may  be  washed  with 
infected  water;  or  contaminated  dust  gains  access  to  the  milk. 

Flies  carry  infection  in  two  ways:  (1)  fecal  matter  containing  the 
typhoid  germs  may  adhere  to  the  fly's  legs,  wings,  or  body  and  be 
mechanically  transported,  or  (2)  the  bacilli  may  be  carried  in  the  diges- 
tive organs  of  the  fly  and  deposited  with  its  excrement.  This  latter 
method  has  not  been  proved.  There  can  be  little  doubt,  however,  that 
the  fly  may  carry  germs  from  infected  excreta  to  foodstuffs. 

The  s[)ecific  germ  not  only  grows  in  milk,  but  also  in  milk  products. 
It  will  live  in  butter  for  many  days,  and  in  cheese  for  a  short  time. 
The  oyster  can  harbor  and  carry  the  typhoid  bacillus.  Infection  of  the 
oyster  usually  takes  place  during  the  time  when  it  is  being  freshened 

Fig.  % 


Positive  Widal  reaction,  showing  agglutinatiou  of  typhoid  fever  bacilli — with  blood  from 
typhoid  patient — at  end  of  thirty  minutes. 

in  water  that  is  contaminated  by  sewage.  Other  foods  may  become 
infected,  particularly  those  which  are  eaten  raw  and  previously  washed 
in  infected  water. 

Predisposinr/  Factors. — Sex  appears  to  have  no  influence  on  the 
occurrence  of  the  disease. 

Season. — Typhoid  fever  is  endemic  in  most  localities.  It  occurs  at 
all  seasons  of  the  year,  although  it  is  commonly  stated  that  it  is  most 
prevalent  in  the  fall  months.  Osier  says  typhoid  is  essentially  an 
autumnal  fever,  and  more  than  one-half  of  his  cases  were  admitted  in 
August,  September,  and  October. 

Frequency  in  Children. — From  200  cases  of  my  own  which  were 
observed  for  the  most  part  in  the  Michael  Reese  Hospital,  Chicago, 
the  following  tabulation  of  ages  is  made: 


PLATE  XI. 


Typhoid.   Ulceration  of  the  Ileum. 

(From  the  Laboratory  of  the  College  of  Physicians  and  Surgeons,  Columbia  University,  New- 
York.     Photograph  by  Dr.  Edward  Learning.) 


TYPHOID  FEVER  429 


0  to  1  year  ....   2      6    years  .   .   .   .14 

1  to  2  years  ....   2       7      "   ....   12 

2  "  .   . 

4  "  .   . 

5  "  ....   16                              200 


.        2 

6           ] 

2 

7 

7 

8  to  14 

.      18 

.      16 

129 


Pathology. — The  opinion  is  general  that  typhoid  fever  in  infants 
produces  less  pronounced  anatomical  changes  than  in  older  children 
and  adults.  In  some  cases,  however,  autopsies  on  comparatively  young 
children  have  shown  anatomical  changes  not  dissimilar  to  those  which 
occur  in  adults.  As  a  result  of  the  typhoid  infection,  hyperplastic 
processes  in  the  intestine  are  more  pronounced  than  the  ulcerative 
ones.  The  typhoid  bacillus  in  the  small  intestine  produces  swellino- 
of  the  solitary  follicles  and  Peyer's  patches.  These  appear  raised, 
of  a  rose-red  color,  and  surrounded  by  a  circumscribed  area  of  red- 
ness. The  process  does  not  remain  localized  in  the  intestine.  Recent 
investigations,  particularly  the  bacteriologic  studies  of  the  blood,  have 
shown  that  in  the  vast  majority  of  cases,  typhoid  bacilli  are  found  in 
the  circulating  blood  before  the  end  of  the  first  week  of  the  disease. 
This  explains  the  presence  of  typhoid  lesions  in  every  part  of  the  body. 
Mallory  believes  that  the  primary  effect  of  the  localization  of  the  typhoid 
bacillus  is  a  multiplication  of  the  endothelial  cells  lining  the  lymph 
channels  in  the  intestine.  In  these  structures  he  has  found  mitotic 
figures  and  a  marked  increase  in  the  endothelium,  with  the  lumen  of 
the  blood  and  lymph  vessels  entirely  obliterated.  The  blocking  of  the 
bloodvessels  results  in  stasis;  very  soon  fibrin  is  precipitated  and 
thrombosis  results.  The  poor  nutrition  consecjuent  upon  this  process 
leads  to  necrosis.  It  should  again  be  emphasized  that  in  infants  and 
very  young  children  ulceration  of  the  solitary  follicles  and  Peyer's 
patches  is  the  exception;  in  older  children  and  adults  it  is  the  rule. 
(See  Plate  XI.) 

When  ulceration  occurs  it  is  most  abundant  in  the  lower  half  of  the 
ileum,  but  the  ulcers  may  occur  in  the  large  intestine  as  well.  The 
lymph  follicles  swell  in  the  early  stages  of  the  disease;  they  are  sharply 
outlined  and  flat,  at  first  deep  red,  then  grayish-red  in  color;  if  necrosis 
occurs  the  patches  become  grayish-yellow,  and  the  central  portion  or  the 
whole  of  the  swollen  patch  becomes  necrotic.  The  necrotic  portion  is 
cast  off  and  a  clean  ulcer  with  sharply  defined,  raised  edges  appears  in 
its  place.  In  some  of  the  patches  no  ulceration  takes  place.  Many  of  the 
solitary  follicles  may  ulcerate.  In  some  cases  almost  the  whole  circum- 
ference of  the  bowel  loses  its  mucous  membrane.  Stenosis  of  the  bowel 
sometimes  results  from  contraction  of  the  connective  tissue.  After  the 
ulcers  have  healed  a  characteristic  granular  blood  pigmentation  is 
observed.  This  is  referred  to  as  the  "shaven  beard"  appearance. 
Peyer's  patches  which  present  a  slightly  depressed  scar,  readily  indicate 
a  past  typhoid.  As  a  rule,  the  process  of  ulceration  is  confined  to  the 
mucosa  and  submucosa,  though  the  muscular  coat  may  be  involved. 
This  may  result  in  severe  hemorrhage  from  branches  of  the  mesenteric 
vessels ;  or  the  serous  coat  may  be  involved  in  the  ulcerative  process  and 


430  IXFECTIOUS  DISEASES 

perforation  into  tlio  abdominal  cavity  results.     In  such  a  case  diffuse 
peritonitis  is  inevitable. 

Characteristic  features  of  the  lesions  are: 

1.  The  ulcers  are  longest  in  the  long  axis  of  the  gut,  thus  distinguish- 
ing them  from  tuberculous  ulcers,  which  are  usually  longest  in  the 
transverse  axis.  The  longitudinal  direction  of  the  typhoid  u1c(Ts  is 
explained  by  the  fact  that  the  degenerative  process  is  confined  alto- 
gether to  the  lym])h  follicles.  In  tuberculosis  the  ulcer  tends  to  spread 
in  the  direction  of  the  lymphatics  which  run  in  a  transverse  direction. 

2.  The  peritoneum  reuuiins  free  from  exudates;  the  peritoneal 
surface  is  usually  smooth  and  glistening,  no  matter  how  closely  the 
ulcer  approaches  it.  Adhesions  between  the  various  loops  of  intestines, 
such  as  frecjuently  observed  before  the  rupture  of  an  appendix,  rarely 
occur  in  typhoid.  This  explains  the  diffuse  peritonitis  which  results 
after  intestinal  perforation. 

In  the  mesenteric  lymph  nodes  the  endothelial  cells  proliferate  enor- 
mously. The  nodes  increase  in  size,  and  a  cut-section  shows  areas  of 
necrosis.  When  the  node  is  cut  through,  its  substance  bulges  out,  giv- 
ing a  convex  appearance.  This  indicates  the  swelling  and  existent 
pressure  within  the  node.  Suppuration  sometimes  occurs.  Ruj)ture 
of  the  node  has  been  observed.  ^lesenteric  nodes  are  always  more  or 
less  enlarged;  in  consistency  they  are  soft;  their  color  is  white  or  pink 
and  the  necrotic  areas  appear  yellowish. 

Spleen. — It  is  usually  three  or  four  times  its  normal  size.  The  cap- 
sule is  distended.  The  organ  is  usually  soft  and  at  times  the  Malpighian 
follicles  are  prominent  and  white  or  gray  in  color.  Their  enlargement 
may  be  a.scribed  to  lymphatic  hyperplasia  similar  to  that  which  occurs  in 
the  lymph  follicles  of  the  intestine.  The  spleen  is  largest  at  the  height  of 
the  disease  and  at  that  time  dark  and  congested,  sometimes  almost  Huid. 

Mucous  Membranes.— XnTion^  mucous  membranes  may  be  involved. 
Bronchitis  antl  laryngitis  occur.  The  cricoid  and  arytenoid  cartilages 
may  become  secondarily  involved,  and  stenosis  of  the  larynx  and  aphonia 
result.     Death  may  occur  as  a  result  of  laryngeal  ulceration. 

Serous  Membranes. — The  serous  membranes  are  not  commonly 
affected.  Pleurisy  is  rare.  Peritonitis  may  occur  in  consequence  of 
perforation  of  an  intestinal  ulcer,  or  rupture  of  a  suppurating,  mesen- 
teric lymph  node.  More  rarely,  peritonitis  is  caused  by  the  migration 
of  tyj)hoid  bacilli  through  an  intact  serosa.  It  seems  more  plausible,  in  the 
light  of  our  j)resent  knowledge,  to  consider  this  a  hematogenous  infection. 

Abscesses  do  occa.sionally  appear  in  every  part  of  the  body  on  account 
of  the  wide  distribution  of  the  typhoid  bacillus,  and  of  a  secondary 
infection  with  pyogenic  organisms.  Suppurative  processes  occur  in  the 
skin,  bones,  or  joints.  Brain  abscesses  have  been  reported,  though 
only  one  case  is  recorded  in  which  a  pure  culture  of  the  typhoid  bacillus 
has  been  found. 

Visceral  Chanr/es. — Parenchymatous  or  fatty  flegenerations  may  be 
found  in  any  or  all  of  the  tissues.  The  liver  and  kidneys  are  swollen, 
and  their  markings  become  indistinct.    In  the  kidney  the  inflammatory 


TYPHOID  FEVER 


431 


changes  range  from  a  mild,  cloudy  swelling  to  a  well-marked  nephritis. 
Pyelonephritis  and  abscess  formation  rarely  occur. 

It  is  assumed  that  the  gall-bladder  is  infected  with  typhoid  bacilli 
in  nearly  every  case,  and  may  lead  to  the  formation  of  gallstones  at 
a  later  period  of  life.  Suppurative  cholecystitis  is  known  to  occur  and 
the  inflammation  extend  into  the  small  bile-ducts.  In  one  of  my  cases 
a  diffuse  cholangitis  was  observed. 

Bronchopneumonia  is  frequently  found  as  a  terminal  lesion  in  fatal 
cases,  though  it  is  sometimes  secondary  to  a  diffuse  bronchitis,  and 
may  be  considered  the  immediate  cause  of  death.  Lobar  pneumonia 
occurs  in  a  few  cases;  occasionally  due  directly  to  the  action  of  the 
typhoid  bacillus. 

The  heart  muscle  usually  shows  a  mild  grade  of  parenchymatous 
degeneration.  In  the  severe  cases  the  myocardial  changes  mav  be 
more  extensive  and  partake  of  the  interstitial  type.  After  recovery,  the 
effect  of  the  myocardial  inflammation  usually  disappears,  though  the 
heart  muscle  may  remain  permanently  damaged.  Owing  to  an  enfeebled 
heart  action,  thrombi  may  form  in  the  auricles  and  be  swept  on  into 
the  general  circulation.  In  this  way  infarcts  occur  in  the  spleen,  the 
kidneys,  and  lungs.  Hemiplegias  have  been  observed  as  the  result  of 
typhoid  fever.  In  two  cases  in  which  autopsies  were  held  thrombosis 
of  the  middle  cerebral  artery  was  found. 

Fetal  Typhoid. — Pregnant  women  suffering  from  typhoid  abort  in 
about  one-half  of  the  cases,  and  the  fetus  is  born  dead  (Klautsch). 
The  causes  advanced  are:  (1)  high  temperature;  (2)  the  accumulation 
of  toxins  in  the  maternal  blood;  (3)  death  of  the  fetus.  It  has  been  found 
experimentally  that  the  intravenous  injection  of  typhoid  cultures  into 
pregnant  ral)bits  and  guinea-pigs  resulted  in  abortion  (Frascarae). 

Intrauterine  typhoid  is  from  the  first  a  general  septicemia.  Bacterio- 
logic  examinations  give  corroborative  evidence  of  the  presence  of  the 
typhoid  bacilli  in  the  blood  of  the  fetus.  They  have  been  found  in 
the  spleen,  in  the  heart's  blood,  and  the  liver.  The  septicemic  nature 
of  the  infection  accounts  for  the  extreme  mortality  in  fetal  and  con- 
genital typhoid.  For  this  reason,  and  possibly  also  because  the  intes- 
tines are  not  functionating,  the  classical  intestinal  lesions  of  typhoid 
are  absent  in  infants.  The  fetus  usually  dies  in  utero.  It  may  be  born 
alive,  but  feeble  and  suffering  from  the  infection,  in  which  case  death 
occurs  within  a  few  days  without  definite  symptoms.  It  is  possible  for 
the  fetus  to  sicken,  recover  from  its  infection,  and  be  born  alive  and 
well.  Infection  does  not  always  occur.  A  pregnant  woman  does  not 
necessarily  transmit  the  disease  to  the  fetus. 

Newborn  or  yoimg  infants  whose  mothers  are  suffering  from  typhoid 
fever  may  exhibit  the  Widal  reaction  without  other  symptoms.  In  such 
cases  it  is  possible  that  the  infants  have  had  typhoid  fever  m  utero,  or 
that  the  agglutinating  power  may  have  passed  from  the  diseased  mother 
into  the  healthy  child  through  the  placenta  or  the  mother's  milk. 

Infantile  Typhoid. — Typhoid  fever  occurs  more  rarely  in  infants 
than  in  older  children  or  adults.     All  the  statistics  since  the  intro- 


432  INFECTIOUS  DISEASES 

duction  of  the  Widal  reaction  and  the  other  more  accurate  means  of 
(Hagnosis  show  that  typhoid  fever  in  children  under  two  years  of  age 
is  not  of  frequent  occurrence.  Infants  are  less  exposed  than  older 
children,  though  they  are  not  known  to  possess  immunity  to  the  infec- 
tion. From  what  has  already  been  said,  it  would  seem  that  the  infant 
is  susceptible  to  typhoid  infection,  since  it  may  become  infected  in  utrro 
through  the  placenta. 

It  appears  from  a  study  of  typhoid  fever  in  infants  that  the  symptoms 
are  essentially  the  same  as  in  adults;  but  the  course  is  shorter  and  the 
mortality  higher.  These  conclusions  must  be  accepted  as  essentially 
correct,  if  the  crises  on  which  they  are  based  are  typical.  It  is  possible, 
however,  that  they  comprise  only  the  severe  varieties,  and  that  many 
milder  cases  have  been  mistaken  for  other  infections. 

The  autopsies  on  infants  show  the  absence  or  slight  degree  of  intes- 
tinal involvement  in  fatal  cases.  In  this  way  they  diflFer  from  the  fatal 
cases  seen  in  adults.  The  enlargement  of  the  mesenteric  nodes  is 
moderate,  although  the  spleen  is  almost  always  considerably  enlarged. 
In  sharp  contrast  to  the  mildness  of  the  pathologic  changes  is  the 
severe  general  infection  during  life,  ^^■ith  its  great  mortality.  In  this 
it  resembles  fetal  more  than  adult  typhoid.  These  conditions  as  they 
occur  in  fetal  typhoid  are  traceable  to  the  blood  infection.  This  also 
obtains,  though  to  a  lesser  degree  in  infantile  typhoid,  and  explains 
the  wide  disproportion  between  the  pathologic  changes  and  the  severity 
and  fatality  of  the  disease. 

The  Course  of  the  Disease. — In  a  general  way  the  cases  among  infants 
may  be  classified  as  mild  and  severe.  The  following  are  illustra- 
tive : 

Mild  Type. — A  male  baby,  aged  twenty  months,  well  developed  and 
of  healthy  parents,  had  occasionally  been  ill  with  mild  gastroenteric 
derangements  which  had  previously  yielded  readily  to  treatment.  After 
the  present  illness  had  persisted  for  a  week  the  mother  sought  medical 
aid.  The  temperature  was  fairly  constant,  ranging  between  101°  and 
103°  F.  The  mother  took  occasion  to  say  that  she  did  not  believe  the 
child  to  be  suffering  from  one  of  his  usual  gastrointestinal  infections, 
because  the  stools  showed  a  more  perfect  digestion  and  were  less  foul- 
smelling  than  during  his  previous  intestinal  attacks.  The  child  was 
pale;  there  was  an  enlarged  spleen;  his  muscles  were  somewhat  flabby; 
he  was  restless.  He  objected  to  restraint  and  did  not  impress  one  as 
being  severelv  ill.  The  Widal  examination  in  a  few  days  was  positive 
and  leukopenia  was  indicated  by  a  leukocyte  count  of  4800.  A  few 
roseolar  spots  were  observed  on  the  abdomen.  The  fever  continued 
in  all  about  sixteen  days  and  recovery  was  uneventful  (Fig.  97). 

Severe  Type. — One  sometimes  sees  very  severe  cases  in  young  children 
where  the  prostration  is  extreme  and  the  fever  high.  These  children  are 
not  inclined  to  play  but  prefer  to  lie  in  their  cribs  or  in  the  mother's  lap 
undisturbed.  Such  a  case  I  saw  in  an  infant  about  twenty-one  months 
old.  He  appeared  greatly  prostrated;  fever  was  high;  the  pulse  and 
respirations  were  accelerated;  spleen  was  large;  the  abdomen  tympan- 


TYPHOID  FEVER 


433 


itic,  and  the  trunk,  both  anteriorly  and  posteriorly,  was  dotted  with 
well-marked  rose  spots.  He  recovered  after  having  a  continued  fever 
for  four  weeks. 

Symptomatology.  Prodromata  and  Mode  of  Onset. — The  symptoms 
preceding  the  actual  onset  of  the  disease  are  very  difficult  to  elicit  in 
infants  and  young  children.  It  is  not  uncommon  that  the  disease  is 
ushered  in  abruptly  and  marked  by  sudden  rise  of  temperature  and 
vomiting.  A  sudden  rise  of  temperature  was  recorded  in  all  the  young 
children  under  my  care;  vomiting  occurred  nineteen  times  at  the  very 
onset  of  the  disease.  Convulsions  are  said  to  occur  rarely.  In  one  of 
my  cases  the  disease  showed  its  beginning  by  a  convulsive  seizure. 
Chill  or  chilliness  was  frequently  complained  of  by  the  older  children 
at  the  beginning,  and  headache  was  more  frequently  noted  than  any 

Fig.  97 


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RES  P. 

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34 

Chart  of  a  mild  case  of  typhoid  fever. 


other  single  symptom  except  fever.  Epistaxis,  which  is  of  common 
occurrence  in  adults,  seems  to  be  less  frequent  in  children.  Out  of 
200  cases  it  occurred  only  four  times  during  the  early  days  of  the  dis- 
ease. Delirium  was  observed  once;  abdominal  and  muscular  pain  was 
present  thirteen  times;  anorexia,  prostration,  nausea,  pharyngitis,  and 
insomnia  were  occasionally  noted  as  prodromal  or  initial  symptoms  of 
the  disease. 

Some  cases  are  ushered  in  by  pronounced  nervous  manifestations  in 
the  form  of  meningeal  symptoms.  I  have  observed  several  such  cases 
in  which  it  was  impossible  during  the  first  few  days  to  exclude  the 
diagnosis  of  meningitis.  A  three-year-old  boy  was  taken  suddenly  ill 
with  high  fever.  His  temperature  was  104°  F.,  he  had  excruciating 
headache  and  vomited  frequently,  and  very  soon  passed  into  a  coma- 
tose condition.  The  neck  was  rigid;  the  pulse  irregular;  the  pupils 
28 


434  INFECTIOUS  DISEASES 

were  symmetrical,  though  there  was  a  sHglit  deviation  of  the  eyes;  the 
rcHexes  were  iiureased;  ankle  clonus  was  present;  Kernig's  sii^n  wa,s 
marked.  The  Widal  was  positive  on  the  second  day  of  observation. 
On  the  fifth  day  the  meningeal  symptoms  had  entirely  disappeared  and 
the  ca^e  ran  the  course  of  a  typical  typhoid. 

Fever. — The  temperature  course  is  not  altogether  typical;  in  older 
children  it  sometimes  rises  gradually  during  tlie  first  week  of  the  disease. 
By  the  end  of  the  first  week  a  maximal  point  in  the  fever  is  reache<l; 
in  which  ease,  after  touching  104°  or  105°  F.,  the  curve  becomes 
remittent.  The  remissions  average  about  1.5°  after  the  disease  is 
fully  established.  AVith  the  advent  of  the  second  week  the  remissions 
ct)ntinue,  though  the  general  temperature  range  may  be  lower.  On  the 
other  hand  intermissions  may  occur.  In  the  severer  cases  hyperpyrexia 
may  continue  for  a  long  time — six  to  eight  weeks  is  not  uncommon — 
or  the  disease  may  be  still  further  protracted  by  relapses  after  the 
temperature  has  fallen  to  normal  or  nearly  normal. 

Among  infants  and  young  children  the  temperature  curve  is  less 
regular  than  above  described.  The  initial  rise  is  sometimes  rapid. 
During  the  acme  of  the  disease  the  fever  often  remains  high,  with 
little  variation  between  the  morning  and  the  evening  temperatures. 
During  the  second  week  the  remittent  character  of  the  fever  is  less 
marked  than  in  adults.  According  to  ^Morse's  figures  it  is  absent 
altogether  in  about  one-half  the  cases.  The  range  of  temperatiu-e  is 
usually  higher,  though  less  significant  of  gravity,  than  in  cases  of  like 
severity  among  adults. 

The  course  of  the  fevei"  is  modified  by  complications,  the  occuirence 
of  pneumonia,  furuncles,  or  otitis  causing  an  increase  in  the  height  or 
an  irregularity  of  the  fever  ciu've.  Excitement  frequently  influences  the 
temperature  curve.  In  the  hospital  wards  it  is  commonly  observetl  that 
all  the  typhoid  fever  children  exhibit  a  slightly  higher  temperature  on 
visiting  days  when  parents  and  friends  are  admitted. 

Fever  sometimes  persists  after  the  disease  has  apparently  run  its 
com"se,  or  after  the  temperature  has  once  come  to  normal.  These  post- 
typhoidal  temperatures  do  not  necessarily  signify  a  relapse;  they  may 
l)e  due  to  complications,  to  intestinal  toxemias,  or  occasionally  to 
inanition. 

Hypothermia. — The  fever  may  fall  below  normal  after  a  tub  bath; 
this  is  particularly  obser\'ed  during  the  third  or  fourth  week  of  the 
di.sea.se.  After  hemorrhage  the  temperature  may  drop  from  103°  F.  to 
08°  or  95°  F.  In  these  cases  the  fever  may  not  rise  for  twenty-four 
hours  or  longer,  when  it  again  ascends  to  the  high  point.  During 
conyalescence  the  temperature  may  be  subnormal — 96.5°  or  97°  F.  for 
days  in  succession.  This  is  particularly  noted  in  protracted  cases  with 
great  emaciation. 

Relapses  occurred  in  10  per  cent,  of  my  cases.  Usually  they  are 
mild  and  run  a  short  course,  though  sometimes  they  are  severe  and 
exceed  the  primary  attack  in  intensity  and  duration.  In  one  of  my 
cases  a  second  relapse  occurred,  that  is,  a  third  attack  of  the  disease. 


TYPHOID  FEVER  435 

The  last  relapse  was  preceded  by  twenty  days  of  normal  temperature, 
and  the  patient  had  apparently  recovered.  During  the  relapse  the 
spleen  usually  becomes  enlarged,  the  roseola  reappear,  and  are  the 
same  as  in  the  primary  attack.  Recovery  occurred  in  all  the  cases  of 
relapse  which  came  under  my  observation. 

Pulse. — In  infants  and  young  children  the  pulse  rate  frequently 
reaches  150  to  180,  which,  in  older  patients,  would  certainly  indicate  a 
fatal  termination.  In  older  children  it  follows  the  type  of  adults  and 
is  relatively  slow.  A  dicrotic  pulse  occurs  only  in  a  small  number  of 
cases.  Intermittence  is  sometimes  noted.  Bradycardia  is  occasionally 
observed  during  the  febrile  period.  In  one  of  my  cases,  that  of  an 
older  child,  the  pulse  varied  between  50  and  70  per  minute  during  the 
entire  febrile  period. 

Heart. — It  is  not  uncommon  to  hear  systolic  murmurs  over  the  base 
of  the  heart.  Many  of  these  murmurs  disappear  as  the  fever  subsides. 
In  some  of  the  cases  an  old  valvular  lesion,  which  has  antedated  the 
typhoid  fever,  explains  the  murmur.  In  a  few*  cases  it  is  due  to 
myocarditis.  A  boy,  ten  years  old,  who  had  suffered  a  severe  attack 
of  typhoid  with  very  high  fever  had  a  striking  irregularity  of  the  pulse, 
which  began  during  the  second  week  of  the  disease  and  continued 
during  the  stage  of  defervescence  and  convalescence.  During  the 
latter  period  the  heart's  action  was  decidedly  irregular.  For  example, 
at  11  o'clock  of  one  day  his  pulse  was  76;  one  hour  later,  without  any 
apparent  cause,  it  was  136.  This  condition  became  more  marked  as 
convalescence  advanced,  so  that  at  one  time  the  heart's  action  was  50 
or  60  per  minute,  while  at  another  hour  it  was  100  or  120  per  minute. 
After  prolonged  convalescence  the  heart's  action  became  regular  and 
the  patient  recovered. 

Sflee-n.—The  spleen  is  usually  enlarged,  but  this  is  not  always  dis- 
covered during  the  first  days  of  the  disease;  at  the  end  of  the  first 
week  it  can,  in  most  cases,  be  palpated.  In  many  cases  it  continues 
swollen  after  the  fever  has  abated;  if  the  spleen  becomes  normal  in 
size,  it  again  becomes  palpable  if  a  relapse  occurs.  The  enlargement 
of  the  spleen  is  elicited  more  easily  by  palpation  than  by  percussion. 
Deep  pressure  is  not  necessary.  Tenderness  upon  palpation  is  seldom 
observed.    A  relapse  may  take  place  without  splenic  enlargement. 

The  Gastroenteric  Tract.  Tongue. — During  the  first  few  days  the 
tongue  may  show  no  changes.  I/ater,  when  the  temperature  is  high,  it 
becomes  coated  and  dry;  the  dorsum  is  white,  the  tip  and  edges  red,  or 
it  may  be  fissured  in  the  longitudinal  direction  and  covered  with  a  dry, 
brownish  fur.  As  the  disease  progresses  the  epithelium  is  desquamated 
and  the  papilla?  stand  out  prominently.  In  some  cases  the  tongue  is 
intensely  red;  in  others  the  papillae  are  prominent,  resembling  the 
strawberry  tongue  of  scarlet  fever. 

Mouth. — At  the  height  of  the  disease  the  mouth  becomes  dry,  and, 
notwithstanding  the  most  careful  nursing,  infection  may  occur.  Catar- 
rhal stomatitis  and  gingivitis  are  not  uncommon,  producing  great  dis- 
tress.    An  increased  flow  of  saliva  is  sometimes  observed. 


436  INFECTIOUS  DISEASES 

Herpes  iahialis  is  thought  to  he  very  infrecjucut,  although  recently 
its  occurrence  has  been  confirmed  by  numerous  reports  in  the  literature. 
It  occurred  in  four  of  my  cases. 

The  Intestines.  Tympanites. — The  abdomen  may  become  distended, 
though  not  as  a  rule  before  the  second  >veek  of  the  disease.  In  some 
of  the  severe  cases  the  tympany  is  extreme  and  may  be  accompanied 
bv  diarrhea;  or  the  tympany  may  be  caused  by  constipation  or  impac- 
tion of  feces.     If  severe,  it  may  cause  respiratory  embarrassment. 

Stools. — Constipation  is  more  frequent  than  diarrhea.  In  some  cases 
diarrhea  may  be  ])resent  during  the  first  week  and  constipation  through 
the  remainder  of  the  disciise.  The  diarrhea  usually  is  slight,  rarely  it  is 
severe  in  character.  In  the  constipated  cases  no  stool  occurs  unless  an 
enema  or  suppository  is  given.  The  bowels  may  move  once  or  twice  a 
day  without  a,ssistance.  In  younger  children  the  stools  are  thin,  fre- 
(ju'entlv  contain  untligcsted  milk  particles,  and  sometimes  nuicus.  They 
may  be  normal  in  color,  and  vary  in  consistency  slightly  from  the  nor- 
mal. Fecal  impaction  occurs  at  times.  In  two  of  my  cases  the  impaction 
occurred  during  the  period  of  convalescence  before  the  patients  had 
been  fed  on  solid  food.  In  both  a  slight  temperature,  marked  tympany, 
and  a  feeling  of  fulness  and  distress  in  the  rectum  occurred.  After 
mechanically  removing  a  lai-ge  quantity  of  the  feces  the  symptoms 
subsided. 

Ilemorrhac/e. — In  general  it  may  be  said  that  hemorrhage  is  not  as 
fre(juent  in  children  as  in  adults.  It  is  more  often  observed  at  the  end 
of  the  second  week  than  at  any  other  period  of  the  disea,se.  I  observed 
hemorrhage  five  times  in  90  cases.  In  2  it  was  slight;  in  1  moderately 
severe ;  in  a  second  case  two  severe  hemorrhages  took  place ;  in  another 
repeated  attacks  of  bleeding  occurred  from  the  bowel;  the  cpiantity  of 
blood  lost  each  time  was  small.  With  each  hemorrhage  the  tempera- 
ture fell  from  103°  to  99°  or  100°  F.;  the  pulse  became  rapid,  the 
skin  blanched;  the  patient  complained  of  abdominal  pain  before  the 
attacks. 

The  ages  of  patients  in  whom  hemorrhages  occurred  were  iis  follows: 

1  6  years  old Eighth  day  of  relapse. 

10    "        " Eleventh      "  disease. 

'  12    "       " Seventh       "  " 

10  "        " .        .        .  Sixth  "  " 

11  "        " Eighth 

Sometimes  stools  containing  a  small  (|uantity  of  blood  and  mucus 
are  observed  during  defervescence,  or  at  the  beginning  of  convalescence, 
and  indicate  the  presence  of  an  ileocolitis  in  contradistinction  to  a 
bleeding  typhoid  ulcer. 

Perforation. — It  would  appear  from  the  literature  that  perforation 
is  not  common.  Several  cases,  however,  have  come  under  my  observa- 
tion. 

There  is  no  regularity  in  the  symptoms,  and  no  symptoms  or  group 
of  symptoms  are  pathognomonic  for  perforation.  Osier  emphasizes 
the  following  points:    Sudden  abdominal  pain  and  alterations  in  the 


TYPHOID   FEVER  437 

pulse  and  respiration.  The  physician  should  never  disregard  such 
warnings,  but  see  the  patient  immediately.  Those  handling  typhoid 
fever  patients  must  remember  that  perforation  comes  in  many  guises, 
and  that  to  detect  its  presence  from  any  constant  combination'  of  signs 
is  hopeless.  There  are,  however,  certain  points  which  stand  out,  and 
of  these  a  most  important  one  is  the  onset.  This  is  sudden  and  usually 
with  pain.  In  the  cases  which  have  had  pain  for  days  before  the  per- 
foration there  may  be  an  exacerbation  which  attracts  attention,  or  there 
may  be  nothing  more  striking  than  before.  After  the  onset.  Osier  says 
the  most  important  constant  features  are  pain,  often  in  severe  par- 
oxysms, tenderness,  and  some  rigidity.  Other  symptoms  may  be  present, 
such  as  vomiting,  sweating,  change  in  the  temperature,  pulse,  and 
respiration,  impairment  of  abdominal  respiratory  movements,  muscle 
spasm,  decrease  in  the  area  of  liver  dulness  (which  is  one  of  value 
if  one  has  careful  notes  of  its  extent  previously,  and  is  of  little  im- 
portance where  there  is  marked  abdominal  distention),  movable  dulness 
in  the  flanks,  and  leukocytosis.  The  final  interpretation  to  be  given  to 
leukocytosis  is  far  from  being  made.  Gushing  and  Finney  show  in  some 
of  their  cases  a  fall  and  not  an  increase  in  the  leukocytes.  The  data 
are:  1.  The  appearance  of  leukocytosis  in  the  course  of  typhoid  fever 
points  toward  some  inflammatory  complications  in  its  early  stage.  2.  If 
this  complication  be  a  peritonitis  and  remain  localized,  associated  pos- 
sibly with  the  preperforative  stage  of  ulceration,  or  with  a  circumscribed, 
slowly  forming  peritonitis  after  perforation,  it  may  be,  and  usually  is, 
signalized  by  an  increase  in  the  number  of  leukocytes.  3.  If,  however, 
a  general  septic  peritonitis  follows,  the  leukocytosis  may  be  but  transi- 
tory and  overlooked,  as  it  disappears  concomitantly  with  the  great 
outpouring  of  leukocytes  into  the  general  cavity. 

Pain,  tenderness, rigidity,  change  in  the  pulse, respiration,  and  temper- 
ature may  all  be  found  without  perforation.  The  only  other  means 
of  making  a  positive  diagnosis  is  exploration. 

McCrae,  in  the  Johns  Hopkins  Reports,  compares  the  operation  for 
perforation  with  that  for  appendicitis.  He  remarks  that  while  explora- 
tion has  often  been  attempted  too  late,  early  operation  has  never 
been  regretted,  and  adds  that  a  positive  diagnosis  of  perforation  in 
every  case  before  operation  is  not  to  be  expected,  nor  is  it  wise  that 
it  should  be  demanded.  What  we  have  to  decide  is  whether  the  con- 
dition is  of  sufficient  gravity  to  warrant  an  exploratory  operation  to 
ascertain  the  existence  or  not  of  some  abdominal  complications. 

Pain  on  Abdominal  Palpation. — Older  children  sometimes  complain 
of  pain  in  the  ileocecal  region;  this  is  found  particularly  in  cases  where 
extensive  ulceration  is  present.  In  younger  children  it  is  obvious  that 
this  sign  is  valueless. 

Respiratory  Organs. — Bronchitis  occurs  very  frequently,  usually  at  the 
end  of  the  first  week.  It  is  present  in  most  of  the  severe  cases,  though 
it  may  appear  in  those  of  mild  type.  Bronchopneumonia  and  lobar 
pneumonia  may  occur;  edema  of  the  larynx  is  rare.  Pleurisy,  abscess, 
and  gangrene  of  the  lungs  have  been  reported. 


438  INFECTIOUS  DISEASES 

Urine. — The  urine  in  the  earlier  .stan;es  of  the  (Hsease  is  seanty,  hyper- 
acid, highly  colored,  with  high  specific  gravity,  "^riie  amount  increases 
as  soon  as  convaleseence  begins,  the  increase  in  some  instances  being 
very  decided,  so  that  ))olyuria  is  occasionally  seen.  The  urin(>,  whirh 
at  first  is  dark,  becomes  lighter  and  almost  colorless  during  the  pcjst- 
fcbrile  period.  The  specific  gravity  varies  also,  depending  upon  the 
height  of  the  fever,  the  quantity  of  licpiid  taken,  the  amount  secreted, 
and  the  presence  or  absence  of  diarrhea.  Urea  is  diminislu>d  during 
the  early  stages  of  the  disease.  Uric  acid  is  increased;  the  chlorides  are 
always  diminished  during  the  early  stages.  'J'he  toxicity  of  the  urine 
is  much  increased;  it  is  double  that  of  normal  urine,  and  is  independent 
of  the  temperature;  it  remains  increased  during  the  entire  course  of 
the  fever,  and  during  convalescence.  Albnmin  is  fre(|uently  present. 
Ilvaline  and  granular  casts  are  observed  in  the  nephritis  of  typhoid. 
Albumin  was  noted  in  8  out  of  90  cases,  and  hyaline  and  granular  casts 
occurred  in  13  of  the  90. 

The  diazo  reaction  of  Ehrlich  is  present  in  90  per  cent,  to  95  per  cent, 
of  oil  cases  of  typhoid  fever,  and  sometimes  occurs  bt^fore  the  Widal 
reaction  can  be  obtained.  Unfortunately  for  the  diagnosis,  it  often  occurs 
in  other  diseases  which  are  readily  confounded  with  typhoid  fever,  such 
a-s  miliary  tuberculosis  and  measles.  To  carry  on  the  reaction  two  solu- 
tions are  recjuired:  (1)  A  saturated  solution  of  sulphanilic  acid  in 
1000  c.c.  of  water  and  50  c.c.  strong  hydrochloric  acid;  (2)  a  0.5  per 
cent,  solution  of  sodium  nitrite.  The  latter  should  be  fresh,  as  it  is 
soon  oxidized  to  sodium  nitrate.  Four  drops  of  the  second  solution  are 
added  to  10  c.c.  of  the  first,  and  the  whole  shaken  with  10  c.c.  of  urine. 
Ammonia  is  then  floated  on  the  surface.  If  the  diazo  reaction  is  present, 
a  bright-red  ring  should  appear  where  the  fluids  meet.  On  shaking, 
the  whole  mixture  becomes  deep  red  in  color  and  the  foam,  too,  is 
red.  All  of  these  changes  must  occur  in  order  that  the  reaction  may 
be  considered  positive.  The  diazo  reaction  is  usually  present  by  the 
end  of  the  first  week,  but  may  be  delayed  until  late  in  the  course  of  the 
disease. 

Kidney  lesions  in  typhoid  fever  are  due  to  the  inflammatory  and 
degenerative  changes  produced  by  the  typhoid  bacillus  itself,  or  by 
other  micro-organisms  which  enter  the  urine  through  the  diseased 
intestinal  wall,  or,  possibly,  in  some  cases,  by  Ijacteria  which  enter  the 
bladder  through  the  lower  urinary  passages.  Bacteriologic  examinations 
of  the  urine  show  the  presence  of  typhoid  bacilli.  In  about  30  })er  cent, 
of  our  cases  the  colon  bacillus,  staphylococcus  pyogenes  aureus  and 
albus  were  found  associated  with  typhoid  bacilli  in  the  urine.  The 
urine  of  fifteen  children,  which  was  examined  l);u'teriologically,  showed 
the  presence  of  the  typhoid  bacillus  five  times.  In  some  cases  the  colon 
and  typhoid  bacilli  were  found  in  the  same  urine. 

The  V>acilli  may  be  found  as  early  as  the  second  week  or  as  late  as 
the  fortieth  or  forty-fifth  flay.  Other  micro-organisms  like  staphylo- 
cocci pyogenes  aureus  and  albus  may  obscure  or  cause  the  disappear- 
ance of  the  typhoid  bacillus.     In  the  cases  that  contain  the   typhoid 


TYPHOID  FEVER 


439 


bacillus,  pus  was  almost  invariably  present,  and  the  pus  explained  in 
part  at  least  presence  of  albumin  in  the  urine. 

The  Blood. — There  is  a  reduction  in  the  number  of  red  cells.  This 
occurs  shortly  after  the  onset  of  the  disease.  The  diminution  increases 
gradually;  probably  the  greatest  reduction  is  noted  about  the  end  of 
defervescence.  On  the  average  it  is  estimated  that  the  maximum  loss 
of  red  blood  corpuscles  is  about  1,000,000  per  c.mm.  Hemorrhao-e  from 
the  bowels  causes  a  further  diminution  in  red  corpuscles. 

The  hemoglobin  gradually  diminishes  with  the  diminution  in  the 
number  of  red  corpuscles;  returning  to  normal  more  slowlv  than  the 
number  of  red  cells. 

The  number  of  leukoc}i;es  is  diminished  in  typhoid  fever.  The 
decrease  is  progressive,  the  corpuscles  becoming  less  as  the  disease 
becomes  more  advanced,  so  that  at  the  height  of  the  disease  about 
4000  or  5000  leukocytes  per  c.mm.  are  noted.  Sometimes  the  number 
may  be  much  lower.  If  the  leukocytes  increase  considerablv,  it  may 
be  assumed  that  some  mfluence  such  as  hemorrhage,  perforation,  or 
inflammatory  complication  is  responsible.  An  increase  above  10,000 
is  abnormal  for  an  uncomplicated  typhoid.  Cold  baths,  however,  may 
cause  a  transient  increase,  so  that  three  or  four  times  the  usual  number 
of  leukocytes  may  be  noted  after  the  completion  of  the  bath.^ 

The  different  varieties  of  leukocytes  show  variations  from  the  normal 
percentage.  At  the  height  of  the  fever  the  small  and  large  mononuclear 
cells  are  relatively  increased ;  the  greatest  decrease  is  noted  in  the  poly- 
morphonuclear neutrophiles.  The  decrease  of  these  cells  keeps  pace 
with  the  increase  in  the  large  mononuclear  forms.  The  percentage  of 
eosinophilic  cells  is  diminished  throughout  the  course  of  the  disease, 
though,  as  convalescence  approaches,  the  eosinophiles  increase  to  a 
point  rather  above  the  normal  average.  In  those  cases  in  which  a 
mixed  infection  has  occurred  as  a  complication  an  increase  in  the 
number  of  leukocytes  is  the  rule,  but  if  the  patient  be  in  a  condition 
of  prostration  the  leukocytes  may  not  only  fail  to  show  any  increase, 
but  they  may  show  a  diminution  in  number.  In  a  complication  as 
severe  as  perforation,  a  complete  absence  of  leukocytosis  or  a  diminution 
in  the  number  may  be  observed. 

The  Skin. — The  most  important  change  is  the  appearance  of  the 
roseolse.  They  occur  from  the  sixth  to  the  tenth  day,  have  been  noted 
as  late  as  the  third  and  fourth  week.  They  consist  of  rose-red  papules 
which  vary  from  2  to  4  mm.  in  size.  These  are  slightly  raised  and 
disappear  on  pressure.  They  tend  to  appear  in  successive  crops;  some- 
times only  a  few  appear,  and  at  other  times  they  are  very  abundant; 
they  occur  most  commonly  on  the  abdomen,  also  on  the  thorax,  on  the 
buttocks;  sometimes  they  may  be  seen  in  the  axilla  and  on  the  flexor 
surface  of  the  arms.  In  one  of  my  cases  the  roseola  became  the  seat  of 
purpuric  spots,  which  persisted  for  several  days,  when  they  disappeared, 
leaving  brownish  stains. 

1  Thayer,  Observations  on  the  Blood  in  Typhoid  Fever,  Johns  Hopkins  Hospital  Reports.  1900. 


440  INFECTIOUS  DISEASES 

Sudaminu  occur  frequently.  Furunculosis  was  very  common  among 
my  cases  and  was  observed  twelve  times.  Onychia  occurred  in  1  case. 
Erythema  may  occur  early  in  the  disease  and  sometimes  confuse  the 
diagnosis  with  scarlet  fever,  particularly  if  a  pharyngitis  be  present. 
The  erythema  may  be  diffuse  over  the  entire  body,  or  it  may  be  local- 
ized to  some  particular  part,  as,  for  instance,  to  the  face;  usually  it  is 
transitory.  Urticaria  may  occur.  In  one  of  my  own  cases  I  noted  it 
early  in  the  second  week.  Bed-sores,  multiple  gangrene,  and  noma 
have  been  recorded.  Henoch  observed  erysi{)elas  of  the  face  with  the 
formation  of  bulhe  in  a  boy  of  eight  years. 

A  fine,  branny  desquamation  occurs  commonly  during  convalescence; 
it  appears  as  an  exfoliation  of  fine  scales.  It  is  not  like  tiie  extensive  ex- 
foliation which  occurs  in  scarlet  fever,  but  resembles  more  that  of  measles. 

Lymph  Nodes. — Edsall  has  recently  observed,  in  a  considerable 
number  of  cases,  that  widespread  though  slight  nodular  enlargement 
occurs  in  typhoid  fever,  in  some  cases  the  enlargement  is  as  marked 
as  that  which  occurs  in  certain  other  infectious  diseases  and  is  usually 
looked  upon  as  distinctive  of  those  diseases.  As  a  rule,  the  nodes  are 
about  the  size  of  buckshot,  but  may  be  larger,  and  most  easily  pal- 
pated in  the  axilla  and  groin.  The  most  active  enlargement  of  the 
lymph  nodes  takes  place  toward  the  end  of  the  disease  or  diu'ing 
convalescence. 

The  Nervous  System. — The  onset  is  frequently  characterized  by  the 
occurrence  of  headache.  In  the  severe  cases  delirium  is  often  noted. 
The  onset  with  meningeal  symptoms  is  not  infre(juent.  Some  of  the 
children  are  particularly  apathetic  after  the  onset  of  the  disease;  they 
sleep  a  great  deal  and  refuse  to  answer  questions.  Younger  children, 
those  under  the  fourth  year,  may  be  very  restless  and  cry  almost  inces- 
santly. On  the  other  hand,  some  of  the  severe  cases  in  infants  are 
characterized  by  a  persistent  stupor.  Tremor  of  the  extremities  and  the 
tongue  is  present  in  the  severe  types  of  the  disease.  Meningitis,  brain 
abscess,  and  neuritis  have  been  also  observed.  Neuritis  affecting  both 
upper  and  lower  extremities,  with  sensory  disturbances  and  atrophy, 
has  been  reported.  The  neuritis  is  often  located  in  a  plexus  (;f  ncrv(\s 
or  in  the  root  or  trunk  of  one  nerve  only.  The  affection  usually  sets 
in  with  excessive  pain,  followed  by  numbness  and  partial  paralysis. 
Sometimes  complete  paralysis  of  the  muscles  supplied  by  the  affected 
nerve  or  nerves  occurs. 

Convulsions  are  usually  of  grave  significance.  Barthez  reported  5 
cases,  of  which  4  were  fatal.  Osier  reports  convulsions  in  a  girl  aged 
eleven  years.  After  the  temperature  had  been  normal  for  eight  days  she 
had  a  convulsion  on  the  left  side  which  lasted  for  three  or  four  hours. 
Recovery  and  consciousness  were  restored  and  she  seemed  quite  herself, 
though  somewhat  confused.  Eleven  days  later  a  tonic  convulsion 
occurred.  "^Fhis  also  involved  the  left  side  and  lasted  five  houi's.  After 
this  seizure  she  was  temporarily  blind,  but  soon  recovered,  "^^rhe  whole 
condition  gradually  improved  and  in  two  months  she  was  perfectly  well. 

Hemiplegia  is  very  rare  in  children,  in  whom  the  condition   is  not 


TYPHOID  FEVER  44I 

an  infrequent  accident  of  the  specific  fevers.  Osier  found  no  instance 
of  hemiplegia  as  a  result  of  typhoid  in  120  cases  of  cerebral  palsies  in 
children.  Wallenburg  studied  a  series  of  160  cases  of  hemiplegia  and 
found  that  4  occurred  during  the  course  of  typhoid  fever.  The  hemi- 
plegia may  occur  during  the  second,  third,  or  fourth  week,  or  during 
convulsions.  Aphasia  usually  accompanies  the  hemiplegia  if  it  is  on  the 
right  side.  The  cause  of  the  hemiplegia  is  softening  due  to  the  throm- 
bosis of  the  middle  cerebral  artery.  Hemiplegia  may  also  be  due  to 
abscess  or  embolism. 

Mental  Abjections  Complicating  Typhoid. — ^"arious  mental  disorders 
may  follow  typhoid  fever,  especially  when  the  disease  has  been  severe 
and  protracted.  A  condition  of  imbecility  and  stupidity  may  last  for 
many  montlis.  INIelancholia  is  perhaps  the  commonest  form  of  mental 
derangement.  Maniacal  attacks  have  been  noted  by  Henoch  in  children 
four  and  seven  years  of  age.  Adams  reports  melancholia  in  two  children. 
Both  recovered  after  several  weeks.  He  also  reports  two  cases  of  mania, 
one  in  a  child  of  seven  and  the  other  twelve  years  of  age.  One  of  my 
patients,  aged  nine  years,  became  demented  at  the  close  of  his  febrile 
period.  During  defervescence  and  convalescence  the  knee-jerks  and 
the  abdominal  and  cremasteric  reflexes  are  frequently  increased,  and 
ankle  clonus  is  frequently  elicited  during  the  same  period.  These 
manifestations  are  probably  more  frequent  in  those  of  hereditary  neu- 
rotic temperament.  Post-typhoid  insanity  is  now  regarded  as  due  to  a 
nutritional  disturbance;  the  result  of  nervous  exhaustion  and  possibly 
insufficient  food  during  the  course  of  the  disease.  Nearly  all  of  the 
cerebral  affections  following  typhoid  in  children  tend  to  recover,  except- 
ing those  cases  where  hemiplegia  occurs. 

Special  Sense  Organs. — Of  the  organs  of  special  sense,  the  ear  is  most 
often  affected.  Furunculosis  of  the  external  ear  is  observed;  it  usually 
occurs  during  convalescence  and  may  be  a  part  of  general  furunculosis. 
Otitis  media  is  relatively  frequent.  It  is  not  definitely  determined  how 
often  the  typhoid  bacillus  is  the  cause  of  these  middle-ear  affections. 
In  the  majority  of  cases  the  infection  spreads  from  the  nasopharynx 
through  the  Eustachian  tube  into  the  middle  ear.  Otitis  media  occurred 
five  times  in  the  cases  which  I  observed.  In  one  it  was  bilateral  and 
four  times  it  occurred  only  in  one  ear.  As  a  rule,  the  middle-ear  affec- 
tions of  typhoid  are  of  a  mild  variety;  sinus  thrombosis,  periostitis,  and 
caries  of  the  mastoid  are  rare  complications. 

Conjunctivitis  sometimes  occurs  and  occasionally  its  manifestations 
are  of  the  severer  kind.  Curschmann  suggests  that  the  conjunctivitis 
may  be  due  to  the  diminished  activity  of  the  lids  and  to  the  diminished 
secretion  of  tears.  I^ate  in  the  course  of  the  disease,  particularly  during 
convalescence,  foci  of  corneal  inflammation  may  occur.  It  is  very  sel- 
dom that  they  lead  to  permanent  disturbances  of  vision.  Feebleness 
of  accommodation  as  part  of  general  postfebrile  debility  is  a  frequent 
symptom. 

Aphasia. — Young  children  who  have  already  learned  to  talk,  fre- 
quently lose  this  power  during  an  attack  of  typhoid  fever,  as  in  other 


442  INFECTIOUS  DISEASES 

acute  affections.  Sometimes  this  aphasia  hecoraes  manifest  (hiring  the 
first  few  days  of  the  ilhiess.  During  convalescenfe  it  is  particularly 
noticeable.  After  the  fever  ha,s  disajipeared,  some  children  seem  to 
have  forgotten  how  to  talk,  (iradually,  however,  the  ability  to  speak 
returns.  Sometimes  the  aphasia  is  due  to  organic  brain  disease,  as  ha^ 
been  mentioned. 

Parotitis  is  less  frequently  observed  now,  since  cleansing  of  the  mouth 
receives  more  attention.  One  gland  is  usually  affected  and  later  the 
other  becomes  involved.  Parotitis  occurs  at  the  height  of  the  typhoid 
at  the  end  of  the  third  week,  l)ut  it  may  occur  later,  even  during  con- 
valescence, and  causes  great  pain.  Parotitis  has  always  been  looked 
upon  as  a  symptom  of  ill  omen  in  typhoid  fever.  Suppuration  some- 
times takes  place  and  may  lead  to  thrombus  of  the  jugular  vein  and 
the  venous  sinuses,  or  cause  acute  edema  of  the  brain.  Henoch  has 
observed  four  cases  of  parotitis  com])li("iting  typhoid. 

Bone  and  Joint  Ajfedions. — In  the  inociiiatioii  experiments  carried 
on  by  Chantemesse  it  was  found  that  the  typhoid  bacillus  could  be 
traced  to  the  medulla  of  bone.  Abscesses  are  found  most  often  in  the 
tibia  and  fcnnu"  more  rarely  in  the  sternum,  ril)s,  and  other  bones. 
Streptococci  or  staphylococci  are  most  commonly  found  with  a  few 
typhoid  bacilli.  In  children  and  young  persons  after  convalescence 
one  occasionally  notices  an  exaggerated  growth  of  the  bones.  Some- 
times a  circumscriV>ed  periostitis  is  recorded,  which  comes  on  without 
very  great  pain,  and  may  undergo  absorption.  Keen  distinguishes  three 
forms  of  arthritis: 

1.  Typhoid  arthritis  proper,  (a)  Polyarticular  variety,  (b)  The 
monarticular  variety  affects  the  larger  joints,  such  as  the  elbow  and 
shoulder,  the  ankle  and  knee,  but  more  fre(juently  the  hip.  As  a  rule, 
pain  is  slight,  though  it  may  be  severe  and  prolonged.  Swelling  is 
observed  in  all  joints  except  the  hip  and  shoulder,  where  it  is  obscured 
by  the  muscular  masses  al:)out  these  joints.     Pus  rarely  forms. 

2.  Septic  typhoid  arthritis  occurs  rarely,  is  usually  polyarticidar,  and 
is  the  result  of  a  mixed  infection  with  the  typhoid  an<l  the  ])V()genic 
bacteria.  It  runs  the  usual  course  of  similar  septic  inflannnation  and 
frecjuently  terminates  fatally  in  spite  of  all  treatment. 

3.  Rheumatic  typhoid  arthritis  is  rare,  it  occurs  where  there  was  a 
previous  rheumatic  history,  it  is  usually  polyarticular  and  may  be 
followed  by  a  multiple  ankylosis. 

The  HemorrJiacjic  Form  of  Typhoid. — Hemorrhagic  eruptions  may 
occur  in  the  course  of  typhoid  fever.  As  a  rule,  they  appear  in  the 
neighborhood  of  the  joints,  and  the  exudation  may  y)e  small  in  f|uantity, 
or  (|uite  large.  Rarely  does  the  tendency  to  bleed  become  general  and 
result  in  hemorrhagic  typhoid.  I  have  seen  a  fatal  hemorrhagic  ca,se 
in  a  little  boy  aged  nine  years.  This  variety  is  characterized  l)y  bleeding 
from  various  mucous  memloranes,  usually  in  connection  with  a  hemor- 
rhagic skin  eruption.  This  is  a  serious  complication  and  nearly  always 
fatal.  One  or  more  of  the  mucous  membranes  may  l)e  involved:  there 
may  be  oozing  from  the  gums,  or  epistaxis;  hematuria  and  hemorrhage 


TYPHOID  FEVER  443 

from  the  vulva  may  be  associated  in  the  same  individuah  Autopsy 
reveals  extensive  internal  hemorrhages,  such  as  meningeal,  pleural, 
peritoneal,  intestinal,  pulmonary — in  fact,  no  tissue  is  exempt  from  this 
universal  tendency  to  bleed.  The  patients  are  much  prostrated;  the 
tongue  is  usually  heavily  coated. 

Hemorrhagic  complication  does  not  occur  at  any  definite  period  of 
the  disease.  It  is  rare  during  the  first  week;  it  is  most  frequently  ob- 
served when  the  fever  is  beginning  to  decline;  it  may  occur  durino-  a 
relapse. 

Occurrence  of  Typhoid  Fever  vnth  the  Exanthemata.  —  Typhoid 
fever  may  be  associated  with  other  acute  infectious  diseases.  The 
presence  of  one  infectious  disease  does  not  exempt  the  patient  from 
another.  If  a  typhoid-fever  patient  is  exposed  to  another  contagious 
disease  he  is  not  immune  to  it,  but  it  may  be  considered  that  on  account 
of  lowered  resistance  his  susceptibility  to  other  infection  is  increased. 
Hence,  typhoid  may  be  associated  with  scarlet  fever,  diphtheria,  measles, 
smallpox,  chickenpox,  whooping-cough,  and  sometimes  malarial  fever. 
These  double  infections  occurred  more  frequently  formerly,  when 
febrile  patients  of  all  kinds  were  huddled  together  in  large  hospital 
wards. 

Duration. — The  duration  of  the  disease  depends  upon  its  severity. 
Mild,  uncomplicated  cases  may  run  their  course  in  ten  days.  The 
severe  cases  in  children  as  well  as  in  adults  may  be  protracted  for 
many  weeks  or  months.  In  cases  in  which  relapse  occurs,  the  disease 
necessarily  runs  a  protracted  course.  Henoch  stated  that  out  of  80 
cases,  11  lasted  from  seven  to  ten  days;  26  from  ten  to  fifteen  days; 
16  from  fifteen  to  twenty  days;  21  from  tw^enty  to  thirty  days;  6 
from  thirty  to  forty-nine  days. 

Diagnosis. — It  is  only  recently,  since  the  new  laboratory  methods  of 
diagnosis  are  employed,  that  the  recognition  of  typhoid  fever  is  possible 
in  nearly  every  case.  In  infants  and  young  children  the  disease  may 
closely  resemble  the  ordinary  intestinal  infections  so  that  the  differen- 
tiation clinically  is  difficult.  In  both  diseases  intestinal  disturbances, 
meteorismus,  vomiting,  and  diarrhea  may  occur.  Meningeal  symptoms 
frequently  mark  the  onset  of  typhoid  fever,  particularly  in  young  chil- 
dren, and  for  the  first  few  days  of  the  disease  it  is  very  difficult,  by  our 
clinical  methods,  to  differentiate  meningitis  from  typhoid.  Typhoid 
fever  may  be  preceded  by  pneumonia ;  in  these  cases  the  recognition  of 
the  typhoid  requires  careful  observation.  In  the  mild  typhoid  of  infants 
and  young  children  the  diagnosis  from  the  clinical  symptoms  alone 
is  difficult  or  impossible.  In  well-marked  cases  it  is  not  difficult  to 
diagnose  the  disease  at  the  end  of  a  week. 

The  splenic  enlargement  is  an  important  sign.  The  spleen  can  usually 
be  felt  on  the  fourth  to  the  sixth  day  of  the  disease.  It  was  enlarged  in 
84  out  of  90  cases  which  came  under  my  observation.  The  splenic 
enlargement  may  lead  to  confusion  in  the  diagnosis,  as  the  spleen  is 
enlarged  in  many  diseases  of  childhood,  particularly  those  which  may 
be  confused  with  typhoid  fever,  such  as  some  of  the  acute  and  chronic 


444  INFECTIOUS  DISEASES 

intestinal  di-sorders  of  cliildhood — in  acute  miliary  tuberculosis,  sepsis, 
and  in  other  acute  infections. 

The  rose  spots  are  a  valuable  aid  to  diagnosis.  They  appear  very 
seldom  in  otlier  diseases.  They  are  pr(\sent  in  rare  cases  of  miliary 
tuberculosis  and  in  cerebrospinal  meningitis.  They  occur  about  the 
end  of  the  first  week.  Their  appearance  in  crops,  their  characteristic 
distribution  over  the  body,  anfl  the  fact  that  they  are  so  commonly 
present  make  them  imj)()rtant  elements  in  the  diagnosis.  It  is  variously 
stated  that  roseohv  do  not  occur  commonly  in  infancy  and  cliildhood; 
my  own  experience  is  that  they  occur  quite  as  fretjuently  as  in  adults. 

Laboratory  Method  of  Diagnosis. — The  Gruber-Widal  reaction  for 
the  diagnosis  of  typhoid  fever  is  based  upon  the  fact  that  the  presence 
of  the  typhoid  bacillus  in  the  body  produces  substances  which  cause 
the  agglutination  of  typhoid  bacilli  when  allowed  to  act  upon  them. 
These  agglutinins  circulate  in  the  blood  and  may  be  found  both  in 
the  serum  and  in  the  corpuscles.  Usually  the  test  is  made  under  the 
microscope.  In  case  dried  blood  is  used  for  the  test,  water  should  be 
added  to  the  blood,  so  that  it  is  half  the  desired  dilution.  One  drop  of 
the  fluid  is  mixed  with  an  equal  cjuantity  of  a  culture  of  the  typhoid 
bacillus  in  bouillon  and  placed  in  a  hollow  ground  slide  under  the 
microscope.  If  the  blood  serum  is  used  the  typhoid  culture  and  serum 
are  mixed  in  the  desired  proportions  and  studied  in  the  same  way. 

If  the  reaction  is  positive  the  typhoid  bacilli  are  agglutinated  in  a 
length  of  time  which  depends  upon  the  dilution  used  and  on  the  specific 
property  of  the  serum.  The  following  changes  are  noted  under  the 
microscope:  The  bacilli  slowly  lose  their  activity;  they  move  about 
more  sluggishly  and  finally  collect  into  larger  or  smaller  clumps.  When 
the  reaction  is  complete  no  actively  motile  bacilli  are  to  be  seen.  At  a 
dilution  of  1  of  blood  serum  to  40  of  the  culture  a  positive  reaction 
should  occur  in  about  thirty  minutes;  1  to  50  in  forty-five  minutes; 
1  to  60  in  one  hour.  The  test  may  be  performed  without  the  use  of 
the  microscope  by  mixing  typhoid  serum  of  a  patient  with  a  typhoid 
culture  in  the  proportions  given  and  watching  the  reaction  in  a  test- 
tube.  If  the  reaction  is  positive,  the  bouillon  becomes  clear  and  small 
whitish  masses,  due  to  the  precipitation  of  the  bacilli,  are  seen  on  the 
sides  and  bottom  of  the  tube. 

For  all  of  the  above  tests  a  culture  of  the  typhoid  bacillus  in  ])ouillon 
should  be  employed.  The  culture  should  be  not  more  than  twenty-four 
hours  old  and  grown  in  an  incubator  at  37°  to  39°  C.  (98°  to  102°  F.). 
It  should  have  been  taken  from  a  growth  in  agar.  If  the  cultures  are 
passed  from  one  bouillon  tube  to  a  next  for  generation,  autoagglutination 
occurs,  and  the  bacilli  cannot  be  used  for  the  (Truber-Widal  reaction. 

Attempts  have  been  lately  made  to  use  homogeneous  emulsions 
of  dead  bacilli  for  the  test.  Unfortunately,  the  dead  cultures  cannot 
be  used  for  more  than  a  month  or  six  weeks,  because  they  are  then 
agglutinated  too  rapidly  by  normal  blood  serum.* 

'  RecenUy  a  "typhoid  agglutometer "  has  been  introduced  by  a  well-known  firm  for  the  purpose 
of  rapid  diagnosis. 


TYPHOID   FEVER  445 

The  Gruber-Widal  reaction  is  present  in  less  than  3  per  cent,  in 
persons  not  suffering  from  typhoid  fever.  It  is  present  at  some  stage 
of  the  disease  in  95  per  cent,  of  typhoid  patients.  It  is  most  often 
first  obtained  at  the  end  of  the  first  or  the  beginning  of  the  second  week. 
It  may  be  delayed,  however,  until  the  sixth  or  seventh  week,  or  until 
all  symptoms  of  the  disease  have  disappeared. 

In  persons  in  whom  icterus  is  present  from  any  cause,  a  positive 
Widal  reaction  occurs,  according  to  Kohler.  Icteric  blood  possesses 
strong  agglutinating  power  toward  typhoid  bacilli,  and  hence  the 
Widal  reaction  would  be  of  no  value  in  persons  suffering  from  jaundice. 
On  account  of  the  persistence  of  the  Widal  reaction  for  long  periods  of 
time  after  typhoid,  the  test  may  be  positive  in  a  person  who  has  passed 
through,  but  is  not  suffering  from,  an  attack  of  typhoid  fever. 

On  account  of  the  lateness  of  the  appearance  of  the  Gruber-Widal 
reaction  in  many  cases  of  typhoid  fever,  another  test  has  been  advocated 
— i.  e.,  the  use  of  blood  cultures  made  from  freshly  drawn  blood.  With 
improving  technique  in  bacteriology  from  year  to  year,  typhoid  bacilli 
have  been  found  in  greater  numbers  in  the  circulating  blood  of  tvphoid 
patients.  Busquer  found  them  in  every  one  of  43  cases  examined  by 
him — in  22  during  the  first  week  of  the  disease,  and  very  often  before 
the  agglutination  reaction  was  present.  The  technique  is  very  simple. 
The  blood  is  withdrawn  by  puncturing  a  prominent  vein  in  the  forearm, 
and  from  +  to  2  c.c.  of  this  blood  is  introduced  into  50  to  150  c.c.  of 
bouillon.  In  twenty-four  hours  the  bouillon  is  seen  to  be  turbid,  and 
if  typhoid  bacilli  are  present  they  may  be  agglutinated  by  a  known 
typhoid  serum. 

The  urine  is  estimated  to  contain  typhoid  bacilli  in  20  per  cent,  to 
50  per  cent,  of  the  cases.  The  feces  always  contain  them  early  and  in 
large  numbers.  However,  the  separation  of  the  bacilli  is  difficult  on 
account  of  the  great  number  and  variety  of  micro-organisms.  The 
method  of  Chantemesse,  known  as  the  gelodiagnosis,  depends  upon  the 
fact  that  only  the  colon  and  typhoid  bacilli  resist  the  action  of  dilute 
carbolic  acid.  The  details  of  this  method  require  laboratory  technicjue. 
The  feces  are  inoculated  into  bouillon.  To  this  bouillon  a  few  drops 
of  typhoid  serum  are  added,  which  cause  the  precipitation  of  typhoid 
bacilli  if  present.  The  precipitate  is  then  plated  on  alkaline  gelatin  to 
which  3  per  cent,  carbolic  acid  has  been  added,  and  which  has  been 
colored  slightly  by  litmus.  The  colonies  of  typhoid  bacilli  are  dis- 
tinguished from  those  of  colon  bacilli  by  remaining  bluish,  while  the 
latter,  by  forming  lactic  acid,  color  the  litmus  red.  The  final  test  for 
the  presence  of  typhoid  bacilli  is  their  agglutination  by  a  known  typhoid 
serum. 

Differential  Diagnosis.  Paratyphoid  Fever. — Since  the  introduction 
of  the  serum  reaction  a  certain  number  of  cases  have  come  to  light 
which  resemble  typhoid,  although  the  Widal  test  remains  negative 
throughout  the  entire  course  of  the  disease.  Closer  examination  of 
the  blood,  feces,  and  urine  yields  a  bacillus  resembling  that  of  typhoid, 
but  not  identical  with  it.     Clinically  the  cases   closely  resemble  true 


446  INFECTIOUS  DISEASES 

typhoid  fever.  As  a  rule,  they  are  mild  and  the  prognosis  is  favorable. 
The  diagnosis  is  made  by  finding  the  paratyphoid  bacillus  in  the  blood 
or  by  the  agglutination  of  paratyphoid  cultures  with  the  blood  of  the 
patient.  Coleman  antl  Buxton  report  the  ca.se  of  a  child,  aged  seven 
months,  from  whom  the  paratyphoid  bacillus  was  Isolated.  The 
reported  cases  are  still  few  in  number,  so  that  a  larger  experience 
and  more  tlefinite  knowledge  is  needed  on  the  subject. 

Tuberculosis. — The  differentiation  ])etwcen  typhoid  fever  and  acute 
miliary  tuberculosis,  particularly  in  children,  may  give  rise  to  great 
difficulty,  and  is  mentioned  in  the  article  on  Tuberculosis.  The  pro- 
(Iromata  of  typhoifl  fever  are  very  short;  in  miliary  tuberculosis 
they  are  very  long  and  are  marked  by  occurrence  of  emaciation.  In 
both  diseases  splenic  enlargement  occurs;  high  fever  is  common  to 
both;  in  rare  instances  an  eruption  occurs  in  miliary  tuberculosis,  which 
may  be  absent  in  typhoid  fever.  In  both  diseases  bronchitis  and  menin- 
geal syniptoms  may  occur.  The  history  should  be  carefully  incpiircd 
into.  '  In  some  of  the  tuberculous  cases  a  history  of  infected  lymph 
nodes  or  joints  and  a  previous  or  existing  affection  of  some  part  of  the 
hmgs  may  aid  in  establishing  the  tuberculous  nature  of  the  disorder. 
A  historv  of  measles  or  whooping-cough,  in  which  the  pulmonary  affec- 
tion has'not  cleared  up,  or  the  continuance  of  a  persistent  cough,  speaks 
somewhat  in  favor  of  the  tuberculous  nature  of  the  disease.  The  fever 
is  not  of  diagnostic  value.  In  miliary  tuberculosis  the  fever  may  be 
remittent  in  character.  The  physical  examination  of  the  lungs  is,  as 
a  rule,  negative  during  the  first  stages  of  miliary  tuberculosis;  at  the 
most,  there  is  evidence  of  a  slight  bronchitis.  Notwithstanding  the 
slight  physical  findings,  dyspnea  and  cyanosis  occur  very  early  and 
the  patients  suffer  from  an  annoying  dry  cough.  Rarely  during  the 
first  stages  of  miliary  tuberculosis  tubercles  appear  on  the  surface 
of  the  pleura  or  pericardium  and  give  rise  to  friction  rubs.  In 
cases  where  this  occurs,  tuberculosis  may  be  suspected.  In  young 
children  the  condition  of  the  pulse  is  not  as  important  as  in  older  chil- 
dren. It  has  already  been  pointed  out  that  the  pulse"  rate  is  rapid  in 
tvphoid  of  children,  though  not  as  marked  as  in  tuberculosis.  Tul)er- 
culous  meningitis,  as  well  as  the  meningeal  symptoms  of  typhoid  fever, 
tends  to  retard  the  pulse  during  the  early  stages.  For  this  reason  the 
pulse  as  a  differential  sign  is  of  relatively  little  value  in  young  children. 
Ophthalmoscopic  examination  should  be  made  in  doubtful  cases.  If 
tubercles  appear  upon  the  choroid  the  diagnosis  of  miliary  tuberculosis 
may  be  made  with  certainty.  They  are  sometimes  observed  very  early, 
or  they  may  appear  a  few  days  before  the  fatal  termination;  one  or  both 
eyes  may  be  affected  and  no  disturbance  of  vision  be  produced  by  the 
tubercles. 

The  sputum  may  be  examined  for  tubercle  bacilli;  Init  it  is  to  be 
remembered  that  the  sputum  may  be  difficult  to  obtain,  and  the  sputum  of 
patients  with  miliary  tuberculosis  very  seldom  contains  tubercle  bacilli. 
The  diazo  reaction  is  found  in  both  acute  miliary  tuberculosis  and  in 
typhoid  fever.     Fortunately,  the  Widal  reaction,  the  examination  of  the 


TYPHOID  FEVER  447 

blood,  urine,  and  feces  for  typhoid  bacilli  make  the  diagnosis  possible 
in  the  most  difficult  cases. 

Tuberculous  meningitis  may  run  a  febrile  course  lasting  for  ten  days 
or  two  weeks,  which  may  simulate  a  typhoid.  In  tuberculous  menin- 
gitis the  headache  is  usually  violent.  The  patients  soon  fall  into  a 
somnolent  condition,  the  pulse  becomes  slow  and  irregular,  the  abdomen 
retracted;  while  in  typhoid  it  is  usually  distended  and  tympanitic. 
Sometimes  the  meningeal  symptoms  do  not  appear  for  one  or  two  weeks. 
These  are  cases  of  acute  general  miliary  tuberculosis  which  terminate 
in  meningitis.  It  has  already  been  noted  that  meningeal  symptoms 
or  meningismus,  so  called,  may  occur  at  the  onset  of  typhoid  fever. 
This  condition  usually  disappears  at  the  end  of  the  first  or  at  the  begin- 
ning of  the  second  week.  Cases  of  true  typhoidal  meningitis  have  been 
reported. 

It  is  sometimes  difficult,  especially  in  infancy,  to  differentiate  intestinal 
infections  with  a  constant  fever  from  typhoid  fever.  In  cases  which 
run  a  protracted  course  and  which  are  marked  by  fever,  diarrhea,  and 
tympany,  repeated  Widal  examinations  should  be  made,  or  the  urine 
and  feces  examined.  The  leukocytes  should  be  counted;  a  leukopenia 
would  indicate  typhoid. 

Influenza  may  be  confused  with  typhoid  feVer.  In  young  patients 
influenza  sometimes  runs  a  course  which  is  characterized  by  high  fever 
and  exhaustion,  without  other  definite  symptoms.  The  fever  in  these 
cases  may  be  remittent  or  intermittent.  The  pulse  and  respirations  are 
rapid  in  influenza.  The  existence  of  an  epidemic  of  influenza,  the 
general  course  of  the  disease,  and  the  serum  test  for  typhoid  are  of 
great  assistance  in  differentiating  the  two  disorders.  Influenza  bacilli 
are  sometimes  found  in  sputum  and  on  mucous  membranes. 

Pyemia  may  be  mistaken  for  typhoid  fever,  especially  in  cases  where 
the  original  focus  of  infection  is  deep-seated.  Fagge  observed  two  cases 
of  pyemia  in  which  there  was  latent  abscess  of  the  lumbar  or  dorsal 
vertebrae.  In  pyemia  the  temperature  is  more  irregular  than  in  typhoid, 
and  profuse  perspiration  and  chills  are  important  distinguishing  ele- 
ments.    Leukocytosis  is  marked  in  pyemia. 

In  young  individuals  who  present  obscure  and  complex  typhoid 
symptoms  the  epiphyses  of  the  bones  should  be  carefully  examined  for 
localized  edema,  redness,  and  pain  due  to  osteomyelitis.  In  osteo- 
myelitis there  is  usually  a  decided  leukocytosis;  in  typhoid,  a  leukopenia. 

Malaria  may  be  mistaken  for  typhoid  fever.  The  reverse  is  also 
true :  typhoid  fever  may  be  mistaken  for  malaria.  This  difficulty  arises 
only  in  those  regions  where  malarial  fever  is  prevalent.  The  blood 
examination  for  plasmodium  and  the  laboratory  tests  for  typhoid  fever 
are  the  most  valuable  and  certain  methods  of  differentiation.  Quinine 
may  be  administered  as  a  therapeutic  test. 

Epidemic  cerebrospinal  meningitis  or  acute  purulent  menincjitis  must 
sometimes  be  differentiated  from  typhoid  fever.  Laboratory  tests  are 
the  most  important  in  making  the  differentiation.  The  Widal  test  and 
the  leukopenia  of  typhoid,  the  leukocytosis  of  epidemic  meningitis,  and 


448  INFECTIOUS  DISEASES 

the  discovery  of  diplococci  in  the  cerebrospinal  fluid  are  points  which 
determine  the  (haj^nosis. 

Appcndicllis  and  typiioid  fever  are  sometimes  mistaken  for  each 
other.  Without  pain  at  some  time  in  the  course  of  the  (Hsease,  there 
can  be  no  acute  surgical  lesion  of  the  abdomen  (llichardson).  The 
diagnosis  of  appendicitis  is  made  from  the  local  symptoms — pain, 
rigiditv,  temjx-rature.  The  onset  in  appendicitis  is  abrupt.  In  place 
of  gurgling  in  this  region  there  is  a  sense  of  resistance  on  palpation,  and 
sometimes  dulness  on  percussion.  In  typhoid  fever  there  is  more  or 
less  temperature  with  pain,  but  without  rigidity  or  tenderness. 

Prognosis.  -This  varies  with  the  epidemic,  with  the  severity  of  the 
disease,  and  the  ])revi()us  health  and  resistance  of  the  child.  Prognosis 
is  grave  in  infants.  Poorly  nourished  children,  or  those  who  have  been 
debilitated  by  constitutional  or  acute  diseases,  have  a  less  favorable 
prognosis  than  those  who  are  robust.  The  mortality  statistics  vary 
within  wide  limits,  Henoch  in  375  cases  had  a  mortality  of  14  per  cent.; 
Blackader  in  100  ca.ses  lost  only  1;  J.  P.  C.  Griffith  I'cports  a  mor- 
tality of  3  per  cent.;  Koplik  reports  a  mortality  of  <S.7  per  cent. 

In  my  own  experience,  in  the  first  series  of  90  cfises,  2  died — 2.2  per 
cent.;  1  died  of  bronchopneumonia  and  exhaustion;  another,  twenty- 
one  months  old,  died  as  a  result  of  multiple  gangrene.  Of  the  last  110 
cases,  4  died,  re])resenting  a  mortality  of  3.()()  per  cent.  Of  these,  1 
died  of  intestinal  j)erforation,  1  of  bronchopneumonia,  the  third  from 
repeated  intestinal  hemorrhage,  and  the  fourth  from  severe  general 
hemorrhage. 

Treatment.  Prophylaxis.  —  The  contamination  of  drinking-water 
being  the  most  prolific  source  of  tyj)hoi<l  infection,  the  disease  can  be 
almost  eliminated  from  cities  by  careful  regulation  of  their  water  supply. 
Similarly,  the  delivery  of  milk  by  dealers  in  whose  families  typhoid 
fever  exists  should  be  absolutely  prohi}>ite(l.  If  a  luirsing  mother  is 
taken  ill  with  ty|)hoid  the  infant  should  be  weaned.  The  antityphoid 
vaccination  of  Wright  has  been  employed  in  the  English  army,  and  it 
is  claimed  that  the  occurrence  of  the  disease  and  the  mortality  have 
both  been  greatly  reduced. 

Great  care  must  be  used,  in  everv  household  in  which  typhoid  fever 
exists,  that  the  discharges  of  the  patient  do  not  infect  healthy  individuals. 
Feces  and  urine,  especially,  must  be  thoroughly  disinfected.  The  best 
antiseptics  for  this  purpose  are  crude  carbolic  acid,  1:10  solution,  or 
chlorinated  lime.  A  pint  of  the  disinfectant  should  be  in  the  bed-pan 
before  use.  All  instruments  and  utensils  conu'ng  in  contact  with  the 
patient  should  be  similarly  disinfected  and  cleansed,  aiul  in  hospitals 
should  not  be  used  for  other  patients.  The  bed-linen  of  the  patient 
must  be  disinfected  before  being  washed.  These  lueasures  should  be 
continued  for  at  least  ten  days  after  the  temperature  has  been  normal. 

In  commimities  in  which  typhoid  fever  is  endenu'c  or  ej)i(lemic,  the 
drinking-water  should  be  boiled.  Persons  changing  their  residence 
from  a  locality  in  which  the  disease  has  not  existed  to  one  in  which 
the  disease  is  common  appear  to  be  especially  susceptible  to  infection. 


TYPHOID  FEVER  449 

General  Management. — Good  nursing  and  careful  hygienic  manage- 
ment are  the  most  important  elements  in  the  treatment  of  typhoid  fever. 
Older  children  should  be  placed  in  bed  and  kept  there  constantly.  The 
use  of  the  bed-pan  and  the  urinal  must  be  insisted  upon.  In  infants 
and  younger  children  this  method  is  not  practicable.  The  restlessness 
in  bed  is  so  great  that  it  is  necessary  at  times  to  lift  them  up  so  that 
they  may  be  held  in  the  nurse's  or  mother's  arms.  The  nurse  should 
note  minutely  the  various  symptoms  which  occur  in  the  progress  of 
the  case,  particularly  those  which  arise  in  the  absence  of  the  medical 
attendant.  The  nursing  record  should  be  carefully  kept;  the  temper- 
ature should  be  taken  by  rectum  at  intervals  of  three  to  four  hours; 
the  pulse  and  respirations  should  be  taken  preferably  when  the  child  is 
asleep.  The  sick-room  should  be  large  and  well  ventilated ;  the  tempera- 
ture should  not  be  too  warm,  not  more  than  65°  to  70°  F.  during  the  day, 
and  a  lower  range  at  night.  Screens  placed  about  the  bed  protect  the  pa- 
tient from  draughts  and  direct  sunlight,  and  in  this  way  add  to  his  comfort. 

A  single  bed  away  from  the  wall  may  be  approached  from  either 
side,  A  woven-wire  spring  mattress,  over  which  is  placed  one  of  hair 
and  upon  this  a  double  blanket,  constitutes  the  best  bed  for  a  prolonged 
illness.  A  rubber  cloth  should  be  spread  under  the  sheet  and  the  sheet 
should  be  kept  smooth  to  prevent  the  formation  of  bed-sores. 

The  position  of  the  patient  in  bed  should  be  changed  from  time  to  time. 
A  change  of  position  tends  to  prevent  hypostatic  congestion  of  the  lungs. 

The  mouth  and  tongue  of  the  little  patients  should  be  kept  scrupu- 
lously clean  by  the  use  of  a  mild  antiseptic  wash,  such  as  a  solution  of 
boric  acid.  The  teeth  also  should  be  cleansed.  These  precautions  with 
reference  to  the  mouth  prevent  stomatitis  and  possibly  other  infections. 

Diet. — In  children  under  two  years  of  age  the  diet  should  be 
managed  somewhat  after  the  plan  that  is  employed  in  the  gastroenteric 
infections  of  infancy.  If  the  stools  are  thin,  frequent,  and  contain 
mucus,  or  are  fetid,' the  use  of  milk  should  be  discontinued  for  a  time 
and  one  of  the  cereal  waters  like  barley,  arrow-root  or  rice-water  should 
be  used.  After  the  stools  show  a  tendency  to  become  more  nearly 
normal,  milk  may  be  resumed,  though  it  is  better  to  give  it  diluted, 
peptonized,  or  at  less  frequent  intervals  than  is  usual  during  health. 
The  quantity  of  milk  may  also  be  reduced,  and  it  may  be  diluted  with 
plain  water  or  with  one  of  the  cereal  waters.  From  five  to  six  ounces 
may  be  given  every  three  or  four  hours. 

If  the  stomach  is  irritable  and  food  is  retained  with  difficulty,  or  if 
the  patient  has  no  desire  for  food,  small  quantities  of  nourishment  may 
be  given  at  short  intervals.  In  cases  where  the  patient  has  been  restless 
he  should  not  be  awakened  from  a  refreshing  sleep  because  the  time 
for  feeding  has  arrived.  During  the  night  the  food  should  be  given  less 
often  than  during  the  day.  When  digestion  is  weak  the  food  should  be 
peptonized.  Egg-albumen  water  is  often  useful.  The  patient  should 
be  given  freely  of  plain  water. 

In  older  children  the  dietetic  management  does  not  differ  essentially 
from  that  of  adults.     The  diet  should  be  fluid  and  easy  of  digestion. 
29 


450  INFECTIOUS  DISEASES 

Milk  whiih  is  clean  and  fresh  should  he  the  principal  article  of  food. 
Dilution  or  peptonization  makes  it  more  easy  of  digestion.  Beef-juice, 
animal  hroths,  cereal  waters,  and  strained  gruels  may  also  be  required 
for  some  of  these  children. 

I  have  still  to  he  convinced  that  the  general  use  of  eggs  and  other 
nitrogenous  or  carbohydrate  foodstuffs  is  desirable  during  the  height 
of  ty])hoid  fever.  Whether  it  has  been  mere  coincidence  or  directly 
the  result  of  the  food,  nevertheless,  rise  in  temperature,  a  feeling  of 
abdominal  discomfort,  and  general  aggravation  of  the  symptoms  have 
followed  most  of  luy  attemj)ts  at  comj)lex  feeding. 

Alcohol  should  not  be  administered  in  a  routine  nuuuier.  It  should 
be  held  in  reserve  as  a  remedy  of  value  to  combat  the  effects  of  the 
tvj)h()i(l  toxemia.  In  cases  of  great  prostration  with  heart  weakness, 
whiskey  or  brandy  may  be  given  in  20  or  30  drop  doses  every  two  or 
three  hours,  to  children  under  two  years  of  age.  In  older  children  the 
dose  may  be  proportionately  larger. 

Diet  during  Convalescence. — When  the  fever  has  fallen  to  normal 
the  patient  recovers  from  the  apathetic  state  which  is  common  to  nearly 
all  cases  of  typhoid  f(>ver.  He  usually  announces  the  return  of  his 
appetite  or  else  comj)lains  of  hunger.  It  is  a  safe  rule  to  postpone  the 
resumption  of  the  usual  dietary  regime  until  the  seventh  or  eighth  day 
of  normal  temperature  has  elapsed.  During  these  seven  or  eight  days 
the  older  children  may  continue  the  use  of  the  broths,  to  which  some 
cereal  like  rice  or  barlev  mav  l)e  added;  orantje-juice  mav  be  given 
during  this  time  and  the  strained  gruel  which  was  permitted  during 
the  course  of  the  fever  may  be  thickened  somew'hat.  Beginning  the 
second  week  of  convalescence,  soft-boiled  egg,  milk-toast,  and  V)aked 
custards  mav  be  allowed.  I^atcr  on,  scraped  beef  slightly  broiled; 
farinaceous  foods,  like  rice,  tapioca,  and  farina;  tender  sweetbread  or 
fish,  and  potato  which  has  been  baked  and  mashed  may  be  gradually 
added  to  the  diet. 

Ili/drothcrapy. — It  is  a  pretty  general  experience  that  children  bear 
the  cold  bath  badly;  that  is,  water  which  has  been  reduced  to  70°  or 
75°  F.  In  recent  years  the  chiklren  that  have  come  under  my  care 
have  been  given  warm  baths  for  a  pyrexia  of  103°  F.  They  are 
placed  in  the  tub  with  water  at  a  temperature  of  88°  to  90°  F.  A 
hammock  is  suspended  over  the  tub  and  when  a  child  is  placed  in 
the  JKith  it  reclines  comfortably  on  the  hammock.  Tubbing  is  continued 
for  five  or  ten  mimites,  in  water  l)etween  8o°  and  90°  F. ;  the  patient's 
temperature  is  usually  reduced  2°  and  the  pulse  and  respirations  fall 
accordingly.  The  children  are  constantly  rubbed  while  they  are  in  the 
water.  This  is  a  detail  often  overlooked.  In  cases  where  the  temper- 
ature decline  was  not  satisfactory,  or  in  those  cases  where  the  fever 
was  unusually  high,  it  was  found  that  if  the  children  were  left  in  the 
bath  ten  or  twelve  minutes  a  greater  reduction  of  temperature  could  be 
obtained.  We  also  observed  that  the  bath-water  was  raised  2°  after 
the  completion  of  the  bath.  Water  that  was  90°  F.  when  the  child 
was  placed  in  it  was  raised  to  92°  F.  when  the  bath  was  completed. 


TYPHOID  FEVER 


451 


In  mild  cases  sponging  with  tepid  water  may  be  employed  and  a 
thin  film  should  be  left  on  the  body  surface.  It  "is  considered  that  the 
evaporation  rather  than  the  temperature  of  the  water  is  effectual  in  cool- 
ing the  body.  The  use  of  guaiacol  externally,  for  reducing  temperature, 
is  not  applicable  as  an  antipyretic  measure  among  infants  and  young 
children. 

Expectant  and  Symptomatic  Treatment. — The  mortality  rate  of 
typhoid  fever  has  steadily  fallen,  although  the  use  of  medicines  in  a 
routine  way  has  steadily  decreased.  With  an  experience  of  200  cases, 
carefully  observed  and  tabulated,  I  rarely  found  it  necessary  to  admin- 
ister drugs  save  as  they  were  indicated  for  some  special  symptom. 
Antipyretic  drugs  of  the  coal-tar  series  have  no  favorable  influence  on 
the  course  of  the  disease,  and  their  use  may  be  very  well  dispensed  with. 

The  antiseptics,  of  which  a  large  number  have  been  employed,  have 
not  won  a  permanent  place  in  typhoid  fever  therapy.  This  group  of 
drugs,  whether  it  be  calomel,  salol,  iodine,  carbolic  acid,  or  any  of  the 
host  of  remedies  which  have  from  time  to  time  been  advised,  have  no 
influence  on  the  duration,  course,  or  mortality  of  the  disease.  Typhoid 
fever  is  not  a  local  disease  of  the  intestinal  tract,  but  is  a  systemic  dis- 
order, with  bacilli  and  toxins  of  the  disease  circulating  freely  in  the 
blood  and  carried  to  the  most  remote  tissues  and  organs  of  the  body. 
Antiseptics,  to  be  effectual,  must  be  general,  not  local;  hence  the 
hiefficiency  of  intestinal  antiseptics. 

The  various  methods  of  serum  and  culture  treatment  are  as  yet  of  no 
practical  value  in  the  treatment  of  the  disease.  E.  Frankel  described 
a  method  of  treatment  by  deep  subcutaneous  injections  of  sterilized 
cultures  of  typhoid  bacilli  grown  on  thymus  bouillon.  He  thought 
that  the  treatment  was  effective,  although  neither  complications  nor 
relapses  were  prevented.  Rumpf  used  cultures  of  the  bacillus  pyo- 
cyaneus  prepared  in  a  similar  way  in  two  patients,  both  of  whom  died 
— one  of  pneumonia,  the  other  of  intestinal  hemorrhage. 

Chantemesse's  serum  was  employed  in  fifty  children.  No  local  or 
general  disturbances  resulted  from  the  injection.  No  striking  cures 
were  effected  with  this  serum. 

At  present  no  specific  typhoid  fever  serum  is  available. 

Treatment  of  Special  Symptotns  and  Complications. — Headache,  as 
a  rule,  requires  little  special  treatment.  The  nurse  should  be  directed 
to  keep  the  patient  quiet;  an  ice-bag  may  be  applied  to  the  head.  The 
headache  generally  disappears  spontaneously  at  the  end  of  the  second 
week.  With  the  treatment  by  baths  they  are  rarely  severe.  Bromide 
of  sodium  may  be  used  in  persistent  cases. 

For  the  restlessness  of  infants  as  well  as  of  older  children,  relief  is 
nearly  always  obtained  by  bathing  and  the  use  of  the  ice-bag.  Bromide 
of  sodium,  0.13  to  0.3  gm.  (2  to  5  gr.),  small  doses  of  trional,  0.06  to 
0.18  gm.  (1  to  3  gr.),  may  be  used  if  a  sedative  is  needed. 

Vomiting. — This  does  not  occur  frecjuently  during  the  height  of  the 
disease.  It  usually  indicates  that  the  food  is  disagreeing,  and  the  best 
plan  is  to  stop  all  food  temporarily.    Small  pieces  of  ice  may  be  admin- 


452  INFECTIOUS  DISEASES 

istercd,  or  at  other  times  small  doses  of  bismuth  may  he  jjjiven  internally. 
'IVaspoonful  doses  of  carbonated  water  or  very  hot  water  are  some- 
times useful. 

Most  of  the  patients  show  a  tendency  to  constipation.  A  daily  enema 
of  normal  salt  solution  is  indicated  in  obstinate  cases;  mild  soaj)suds 
or  oil  injections  may  be  used.  The  use  of  the  \o\v^  rectal  tube,  as  a  rule, 
is  unnecessary.  The  small  rubber  point  of  the  fountain  syrin>i;e  is 
sufHcient;  a  rounded  glass  point  is  preferable,  as  it  can  be  disinfected 
and  boiled.  These  patients  should  have  one  bowel  movement  a 
day.  If  fecal  imj)action  occurs,  feces  must  be  broken  up  and  extracted 
by  the  fingers  after  injections  of  sweet  oil  or  ox-gall.  Laxatives  are 
rarely  necessary;  if  used  at  all,  only  the  milder  ones,  such  as  milk  of 
magnesia,  3.75  to  7.5  c.c.  (1  to  2  drams),  or  castor  oil,  should  be  used. 
If  three  or  four  stools  occur  during  the  twenty-four  hours,  little  or  no 
mc(licinal  treatment  is  called  for.  If  this  number  is  excetnled,  some 
measure  should  be  employed  to  control  the  diarrhea.  Subcarbonate 
or  subnitrate  of  bismuth  may  be  given  in  0.6  gm.  (10  gr.)  doses  to  chil- 
dren of  two  years  or  over.  The  stools  should  be  inspected  carefully; 
if  they  contain  undigested  food  masses,  the  milk  should  l)e  tliluted  or 
discontinued  temporarilv.  Tanningen  or  tannall)in  in  O.OO  to  0.18  gm. 
(1  to  3  gr.)  doses  may  also  be  given  to  children  un<lcr  three  years  of 
age.  In  obstinate  cases  small  doses  of  opium  may  be  required.  The 
medicinal  treatment  of  the  diarrhea  should  not  be  carried  too  far; 
obstinate  constipation  sometimes  results,  which  may  cause  pronounced 
toxemia  and  tympany. 

The  dietetic  treatment  of  tympanites  is  similar  to  the  treatment  of 
diarrhea.  Warm  compresses  or  turpentine  stupes  made  by  mixing 
one  part  of  spirits  of  turpentine  with  six  parts  of  sweet  oil  may  be  applied. 
T1k>  abdomen  is  covered  with  a  thick  piece  of  flannel  which  has  been 
dil)j)e(l  in  hot  water,  wrung  out,  and  when  sufficiently  cool  aj)plied  to  the 
alxlomen  and  covered  with  oiled  silk.  The  rectal  tube  may  be  used 
with  caution;  a  rectal  injection  often  brings  relief.  The  meteorism  is 
not  infrequently  the  result  of  a  fermentation  process  in  the  bowels. 
Salol,  the  carbonate  of  guaiacol,  or  charcoal  tnay  be  tried  in  these  cases. 
If  severe  alxlominal  j)ain  occurs,  the  use  of  an  opiate,  preferably  pare- 
goric, may  be  necessary. 

Upon  the  first  occurrence  of  a  hemorrhage  from  the  bowels  the 
patient  should  be  enjoined  the  utmost  (|uiet".  The  baths  should  be 
discontinued  and  the  food  limited  to  the  smallest  possible  amount. 
During  the  first  f(>w  days  a  few  teaspoonfuls  of  cold  milk  should  be 
given  and  the  patient  may  be  permitted  to  swallow  small  pieces  of  ice. 
An  ice-bag  should  be  applied  to  the  abdomen.  Opium  in  the  form  of 
paregoric  or  Dover's  powder  should  be  administered  in  sufficient 
quantity  to  quiet  peristalsis.  In  giving  any  of  the  opium  preparations, 
their  efiect  should  be  watched,  and  sufficient  time  should  be  allowed  to 
elapse  to  judge  of  the  action  of  the  initial  dose  before  a  second  dose 
is  given;  0.001  to  0.0016  gm.  (^  to  ^V  gr.)  of  morphine,  combined  with 
0.00021  gm.  (^^0  gr.)  of  atropine  may  be  given  to  children  three  years 


MALARIA  453 

old.  A  solution  of  2  per  cent,  gelatin  may  be  administered  by  mouth  or 
by  rectum  to  control  hemorrhage.  The  use  of  gelatin  hypodermically 
is  unsafe,  as  it  may  cause  toxemia,  and  it  has  caused  tetanus  in  a  num- 
ber of  cases.  Severe  hemorrhage  is  sometimes  followed  by  anemia  or 
collapse.  In  such  cases  hot  saline  enemata  or  the  infusion  of  normal 
salt  solution  under  the  skin  or  into  the  veins  is  indicated. 

Heart  weakness  should  be  treated  by  stimulants.  It  is  sometimes 
due  to  change  in  the  myocardium  or  to  general  prostration.  These 
cases  are  treated  by  the  use  of  brandy  or  whiskey,  digitalis,  strophanthus, 
or  strychnine,  either  by  mouth  or  hypodermically;  0.00013  gm.  (-g-^gr.) 
of  strychnine  may  be  given  three  or  four  times  daily  to  a  child  one  year 
of  age;  0.016  c.c.  to  0.12  c.c.  (^  to  2  min.)  of  tincture  of  strophanthus  or 
digitalis  is  the  usual  dose  for  a  one-year-old  child.  When  collapse 
occurs,  nitroglycerin  is  indicated.  For  a  child  one  year  old  the  dose  is 
0.000026  to  0.00013  gm.  (^sW  to  ^h  gr-)- 

Parotitis  should  be  treated  by  the  application  of  an  ice-bag  to  the 
swollen  gland.  If  fluctuation  occurs  it  should  be  incised.  Furuncles 
should  be  treated  by  incision. 

Pulmonary  complications,  as  bronchitis  and  pneumonia,  and  also 
neuritis  and  joint  affections  should  be  treated  on  the  lines  which  are 
indicated  in  these  disorders. 

If  the  attending  physician  suspects  that  perforation  is  threatening, 
or  if  it  has  actually  occurred,  the  case  is  distinctly  a  surgical  one  and 
operative  procedure  should  be  instituted  if  the  diagnosis  is  reasonably 
certain  and  the  condition  of  the  patient  permits. 


MALARIA. 

By  JOHN  RUHRAH,  M.D. 

Malaria  is  an  infectious  disease  caused  by  the  hemacytozoon  de- 
scribed by  Laveran.  It  is  characterized  by  paroxysms  of  intermittent 
fever  of  a  quotidian,  tertian,  or  quartan  type.  In  other  cases  there  is 
a  remittent  fever.  There  may  be  rapidly  fatal  or  pernicious  forms  or 
there  may  be  a  cachectic  condition  with  anemia  and  an  enlarged  spleen. 

Etiology. — Owing  to  a  better  understanding  of  malaria  and  its  causes, 
and  to  the  drainage  of  marsh  land,  the  disease  is  becoming  less  and 
less  frequent  in  civilized  countries.  A  transmitted  immunity  has  been 
regarded  as  lessening  its  prevalence. 

In  this  country  the  disease  is  found  in  a  number  of  places.  In  many 
localities  along  the  Atlantic  coast  and  throughout  the  Southern  states 
it  is  seen  with  comparative  frequency,  but  in  the  Northwest  and  West 
cases  are  more  unusual.  In  the  tropics  it  is  most  frequent  in  spring 
and  fall,  while  in  summer  and  winter  there  is  but  little.  In  the  tem- 
perate climates  a  few  cases  may  be  seen  in  spring,  but  the  majority  are 
observed  in  August,  September,  and  October,  and  even  in  November. 

Negroes  are  supposed  to  be  less  susceptible  than  the  white  races. 


454  INFECTIOUS  DISEASES 

It  is  undoubtedly  true  that  the  disease  may  be  contracted  in  idero, 
when  the  mother  has  the  disease  in  a  severe  form.  This  is  usually, 
however,  a  very  rare  occurrence. 

Mode  of  Infection. — The  ordinary  mode  of  infection  is  through  the 
bite  of  a  certain  tromis  ('anopheles)  of  mosquito,  which  acts  as  the  inter- 
mediate host  for  the  malaria  parcosite.  vSo  far  the  parasite  hius  been 
found  only  in  these  mostjuitoes  and  in  man. 

The  Parasite. — The  parasite  is  a  hemacytozoon,  or  a  panxsite  which 
attacks  the  red  blood  cells.  There  are  a  number  of  different  hema- 
cytozoa  found  l)oth  in  man  and  in  animals. 

The  hemacytozoon  of  malaria  was  first  discovered  by  Laveran  in 
1880;  subse(iuently  it  was  described  very  accurately  by  Celli  and  Marchi- 
afava;  then  (iolgi  noted  that  the  fever  and  the  segmentation  occurred 
at  the  same  time.  In  this  country  the  organism  has  been  thoroughly 
studied  by  Osier,  Thayer,  and  many  others.  Manson  formulated  the 
theory  that  the  infection  was  due  to  the  mos(juito,  and  Ross  demon- 
strated the  development  of  the  parasite  in  the  body  of  the  intermediate 
host  (mosquito).  The  disease  was  produced  in  young  Manson  by 
letting  infected  mosquitoes  bite  him. 

There  are  three  forms  of  the  parasite  known— the  tertian,  (juartan, 
and  the  estivoautumnal. 

1.  The  tertian  parasite  completes  its  cycle  of  development  in  the 
human  body  in  forty-eight  hours.  When  first  noticed  it  is  a  small, 
oval  or  irregular-shaped  mass,  without  any  pigment,  in  the  centre  of 
a  red  l)loo(l  cell.  This  is  about  2/i  in  diameter.  (A  red  blood  cell  is 
al)out  7/i  in  diameter.)  It  looks  very  much  like  the  spore  forms  seen 
during  the  chill,  and  the  parasite  looks  as  if  it  were  covered  by  part 
of  the  red  cell.  This  develops  rapidly  and  in  a  few  hours  pigment  may 
be  seen.  This  is  fine,  granular,  and  brown  in  color.  The  pigment  is 
arranged  about  the  periphery  of  the  y)arasite  and  there  is  a  clear  area 
partly  transparent  and  partly  milky  white  which  contains  no  pigment. 
There  is  distinct  ameboid  movement,  protrusions  being  put  forth  and 
then  withdrawn.  As  development  goes  on  the  red  blood  cells  con- 
taining the  parasite  seem  larger  than  the  others  and  the  color  is 
paler,  a.s  if  the  hemoglobin  had  been  absorbed.  The  pigment  in  the 
parasite  increases.  Just  before  the  chill  the  parasite  fills  the  most 
of  the  red  blood  cell.  The  pigment  becomes  grouped  in  the  centre 
of  the  parasite  and  the  protoplasm  splits  from  the  centre  to  the 
periphery  into  from  fifteen  to  twenty  segments,  the  lines  of  fission  being 
like  spokes  of  a  wheel.  These  segments  are  the  so-called  spore  forms 
and  they  enter  the  red  blood  cells  and  go  through  another  cycle  of 
development.  Some  of  the  full-grown  parasites  do  not  segment,  but 
remain  with  actively  moving  pigment  granules.  These  are  the  so-called 
gametocytes  or  sexually  differentiated  parasites. 

2.  The  quartan  parasite  is  quite  rare  in  the  United  States.  It  takes 
seventy-two  hours  to  complete  its  cycle  of  development  in  its  host  and, 
hence,  the  chill  and  fever  are  seen  on  every  fourth  day.  The  early 
stages  are  like  the  tertian.    The  granules  are  larger  and  darker,  however. 


MALARIA 


455 


and  there  is  not  so  much  movement.  Bj  the  third  dav  the  parasite  is 
usually  quite  still  and  the  pigment  at  the  periphery.  The  red  blood 
cell  is  of  a  dark  yelloT^nsh-green  or  brassy  color.  On  the  fourth  dav 
the  pigment  moves  toward  the  centre  and  is  seen  in  radiatino-  lines 
which  give  the  parasite  a  rosette  appearance.  The  parasite  seo^ments 
into  from  six  to  twelve  spore  forms.  There  are  some  which  do  not 
segment  (gametocytes)  as  in  the  tertian  form. 

3.  The  estivoautumnal  parasite  is  the  parasite  of  the  more  irregular 
fevers.  Its  cycle  probably  takes  twenty-four  to  forty-eight  hours,  and 
after  a  week  there  are  seen  curious  crescentic  forms.  The  parasite  is 
smaller  than  the  preceding,  being  about  half  the  size  of  the  red  blood 
cell.  There  is  but  little  pigment.  Usually  there  are  seen  small  hvaline 
bodies  with  one  or  two  pigment  granules  near  the  peripherv. '  The 
later  stages  of  development  must  be  studied  in  the  internal  circu- 
lation, as  in  the  blood  of  the  spleen.  The  corpuscles  containing  the 
parasite  shrink  and  are  of  a  distinct  yellowish-green  color.  After 
about  a  week  large,  oval  or  crescentic  forms  are  seen.  These  have 
pigment  in  the  centre  and  often  have  the  remains  of  a  red  blood 
cell  adhering  to  them.  They  are  the  sexually  differentiated  forms  or 
gametoc}i:es. 

The  gametoc\1:es  of  all  the  forms  do  not  develop  any  further  in  the 
human  blood,  but  they  do  upon  the  slide  or  in  the  intermediate  host. 
The  male  parasite  gives  off  flagellse  which  enter  the  body  of  the  female. 
If  this  occurs  in  the  stomach  of  a  mosquito  the  fecundated  parasite 
enters  the  wall  of  the  stomach  and  undergoes  further  development. 
Two  days  after  the  mosquito  has  bitten  the  person  whose  blood  contains 
the  malaria  parasite,  small  refractive  bodies  may  be  seen  in  the  wall 
of  the  stomach  of  the  mosquito.  In  about  a  week  these  have  developed, 
become  striated,  and  burst  into  myriads  of  spindle-shaped  sporozoids. 
These  get  into  the  poisonous  salivary  glands  of  the  mosquito  and, 
escaping  by  the  ducts,  infect  the  individual  bitten.  On  entering  the 
blood  of  the  host  these  sporozoids  develop  into  young  parasites. 

As  stated,  the  genus  of  mosquito  which  acts  as  intermediate  host  is  the 
anopheles,  of  which  numerous  species  have  been  described.  The  com- 
mon genus  of  mosquito  is  the  culex.  The  two  are  easily  distinguished. 
The  anopheles  has  two  large  palpi,  one  on  either  side  of  the  proboscis. 
The  wings  are  mottled.  When  on  the  wall  or  ceiling  the  bodv  is 
inclined  away  from  the  wall  at  an  angle  of  forty-five  degrees  or  more. 
The  harmless  culex  has  small  palpi,  no  spots  on  the  wings  beyond  the 
veins,  and  the  body  is  parallel  to  the  wall  and  usually  the  two  posterior 
legs  are  crossed  over  the  back.  The  culex  is  common  in  the  city,  while 
the  anopheles  is  found  in  the  country. 

Pathology. — ^Malaria  is  rarely  fatal  in  infants  and  children  in  this 
country.  The  fatal  cases  are  the  so-called  pernicious  forms.  The 
lesions  in  malaria  cachexia  are  sometimes  seen  when  the  child  dies  of 
some  intercurrent  affection.  The  changes  are  much  the  same  as  in 
adults.  In  the  pernicious  forms  there  is  enlargement  of  the  spleen 
and  liver.     The  blood  corpuscles  are  destroyed  and  the  serum  of  the 


456 


INFECTIOUS  DISEASES 


blood  may  be  tinojed  with  hemoglobin.  In  the  chronic  cases  there  is 
|)i<i;nientation  of  tjie  spleen  and  liver  and  of  many  other  tissues,  as  in 
the  brain  and  kidneys.     Nephritis  may  be  found  occasionally. 


Fig.  98 


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Temperature  chart  of  tertian  type  of  malaria. 

Symptomatology. — The  younger  the  child  the  more  apt  is  the  disease  to 
be  irregular  in  its  forms.  After  five  or  six  years  of  age  the  adult  type  of  the 
disease  is  met  with.  If  the  infection  is  with  the  tertian  type  of  organism 
the  paroxysm  comes  on  every  other  day  (Fig.  9S).  If,  as  most  usually 
happens  in  young  children,  there  is  a  double  infection  with  the  tertian 
organisms,  and  they  mature  on  alternate  days,  the  paroxysm  will  come 
every  day,  the  so-called  quotidian    fever  (Fig.  99).      If  the  quartan 


Fig.  99 


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Temperature  chart  of  quotidian  type  of  malaria. 

organism  is  found  the  paroxysm  will  come  every  fourth  day.  In  this 
countrv  the  quartan  parasite  is  so  rare  as  to  be  practically  disregarded. 
If  the  infection  is  with  the  estivoautumnal  parasite  there  may  be  an 


MALARIA 


457 


intermittent  fever  of  a  daily  or  of  an  irregular  form,  or  there  may  be  a 
remittent  fever,  the  temperature  going  up  and  down,  but  seldom  if 
ever  reaching  normal  (Figs.  100  and  101).  This  may  be  mistaken  for 
typhoid  or  may  go  under  the  name  of  bilious  fever  or  typhomalarial 
fever  or  under  some  local  designation.  In  the  pernicfous  form  of 
malaria  the  parasite  found  is  of  the  estivoautumnal  type. 


Fig.  100 


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Temperature  charts  of  estivoautumnal  type  of  malaria. 


The  Malarial  Paroxysm. — In  older  children  the  parox^'sm  resembles 
the  adult  type.  The  child  may  have  been  feeling  quite  well  previously, 
or  may  have  been  complaining  of  not  feeling  as  well  as  usual.  The 
attack  starts' with  a  chill,  which,  in  younger  children,  may  be  replaced 
with  a  convulsion.  This  may  be  preceded  by  stretching  and  yawniing, 
and  it  is  not  uncommon  to  have  an  attack  of  vomiting  at  the  outset 
or  even  several  loose  bowel  movements.    The  child  complains  of  feeling 


45S  IXFECTIOr'S  DISEASES 

cold  and  looks  blue  and  peaked.  There  may  be  shaking  even  of  a  severe 
form.  The  child  wishes  to  be  covered  up  in  bed.  The  hands  and  feet 
are  cold,  the  luiils  and  lips  i)lue,  and  cyanosis  may  be  very  marked. 
The  temperature,  especially  if  taken  i)y  the  rectum,  is  elevated.  This 
cold  stage  lasts  from  a  few  minutes  to  an  hour  and  then  there  is  a  stage 
of  high  fever,  the  feeling  of  cold  giving  way  to  one  of  heat,  and  the 
child,  while  still  feeling  badly,  does  not  complain  as  much  as  before. 
There  is  usually  intense  thirst  and  headache.  The  temperature  is 
about  104°  or  l()o°  F.,  but  may  even  go  above  that.  After  from  half 
an  lujur  to  four  or  five  hours  of  high  temperature  the  fever  breaks. 
There  may  be  a  profuse  sweat,  but  this  is  not  as  common  in  children 
as  in  adults.  The  temperature  drops  to  normal  or  below\  The  child 
feels  weak,  but  after  a  short  time  feels  about  us  well  as  usual. 

Under  five  years  of  age  the  attacks  are  not  so  typical.  The  chill  may 
be  entirely  replaced  by  a  convulsion,  by  an  attack  of  yawning  or  stretch- 
ing, or  by  an  attack  of  vomiting  or  of  diarrhea.  There  may  be  simply 
an  attack  of  cyanosis  without  anything  else  of  note.  The  lips  and  nails 
may  be  blue  and  the  hands  and  feet  cold.  The  expression  may  be 
noticeable,  the  face  being  pinched  and  the  eyes  sunken.  The  tempera- 
ture if  taken  is  found  to  be  high.  In  some  the  chill  may  be  replaced 
by  a  cold  nose  or  some  such  trifling  symptom,  and  in  many  there  is 
nothing  definite  noted.  In  young  infants  the  fever  is  quotidian  and  this 
is  usually  due  to  a  double  infection  with  a  tertian  parasite,  although  the 
estivoautumnal  may  be  found.  A  single  infection  with  a  tertian  para- 
site is  not  so  common. 

Of  greater  importance,  as  they  are  more  apt  to  be  misinterpreted, 
are  the  irrec/ular  jorins.  The  child  may  have  no  paroxysm  at  all  and 
the  fever  may  be  of  a  very  irregular  type,  so  that  the  diagnosis  will  have 
to  be  made  upon  other  things.  The  fever  may  be  intermittent  in  type, 
going  up  and  down  at  irregular  intervals,  and  it  mav  be  overlooked 
unless  the  temperature  is  being  taken  at  short  periods.  I  have  seen 
children  whose  morning  and  evening  chart  did  not  show  anything,  but 
in  whom  fever  of  an  irregular  type  was  revealed  by  a  two-hour  or  a 
four-hour  chart.  Even  a  four-hour  chart  may  not  indicate  it.  Another 
form  which  is  apt  to  be  mistaken  for  typhoid  is  the  remittent  tvpe.  In 
this  the  child  has  a  continuous  fever,  the  temperature  going  up  and 
down,  but  seldom  if  ever  touching  normal.  There  are  also  subacute 
forms  in  which  the  child  is  never  very  sick,  but  is  more  or  less  listless, 
well  one  day  and  sick  the  next,  sallow  and  anemic,  and,  as  in  all  the 
other  forms,  with  an  enlarged  spleen. 

If  the  disease  is  untreated  it  apparently  gets  well  of  its  own  accord 
after  several  weeks  or  more,  to  recur  at  some  future  time,  or  it  leaves 
the  child  with  the  subacute  form  or  with  a  condition  known  as  a  malaria 
cachexia.     Repeated  attacks  of  the  disease  will  produce  the  cachexia. 

Malaria  Cachexia. — These  cases  may  be  mistaken  for  some  form  of 
anemia  and  the  real  cause  be  overlooked.  There  is  a  severe  grade  of  a 
secondary  anemia.  The  child  is  pale,  sallow,  and  the  skin  has  a  muddy, 
yellowish  tint.     The  eyes  are  sunken   and   the  facial  expression  woe- 


MALAEIA  459 

begone.  The  tongue  is  coated  and  the  appetite  is  lost.  There  is  liable 
to  be  an  indigestion  with  attacks  of  vomiting.  Constipation  is  the  rule, 
but  there  may  be  diarrhea.  The  spleen  is  large  and  hard.  In  some 
instances  the  spleen  may  be  enormously  enlarged;  the  liver  may  also 
be  enlarged.  There  is  slight  edema  about  the  feet  and  ankles.  There 
is  a  tendency  to  hemorrhage.     The  urine  may  contain  blood. 

Pernicious  Malaria. — This  is  rare  in  children  in  this  country.  The 
attack  generally  starts  with  vomiting,  a  convulsion,  and  high  fever. 
In  some  instances  the  convulsions  continue  or  the  child  becomes  coma- 
tose. Cases  have  been  reported  where  the  coma  came  on  with  each 
paroxysm  and  disappeared  when  it  was  over.  The  diagnosis  is  by  blood 
examination,  and  unless  treated  with  subcutaneous  or  intravenous  injec- 
tions of  quinine  death  occurs. 

Associated  and  Coiwplicating  Conditions. — The  enlargement  of  the 
spleen  is  one  of  the  most  noteworthy.  I  have  never  seen  a  case  of 
malaria  in  a  child  where  the  spleen  could  not  be  palpated.  The  spleen 
seems  to  get  large  during  the  paroxysm  and  may  be  felt  just  below  the 
margin  of  the  ribs.  Usually  it  is  constantly  enlarged.  In  the  chronic 
forms  the  spleen  may  reach  an  enormous  size  and  be  mistaken  for  some 
other  condition.  Unless  very  chronic  the  spleen  returns  to  normal  or 
nearly  normal  size  when  the  child  is  treated  with  quinine.  In  the  very 
large  spleens  the  size  is  greatly  diminished,  but  treatment  will  not 
cause  it  to  return  to  the  normal  size.  It  is  surprising  how  rapidly  the 
spleen  may  diminish  in  size  under  quinine. 

Anemia  is  marked  owing  to  the  destruction  of  the  red  blood  cells. 
There  is  a  slight  hematogenous  jaundice  when  the  disease  is  severe 
or  where  it  has  persisted  any  length  of  time.  Leukocytosis  is  rare  in 
malaria. 

Herpes  is  frequently  seen  about  the  lips.  Coryza  is  not  uncommon 
and  cases  have  been  observed  where  a  coryza  may  take  the  place  of  the 
sweat.  Bronchitis  is  frequently  seen  in  malaria.  Pneumonia  of  malarial 
origin  was  formerly  described,  but  probably  is  merely  a  complicating 
affection.  AATiat  does  occur  in  children  is  a  severe  congestion  of  the 
lungs  which  gives  marked  signs.  This  may  be  limited  to  one  lobe  and 
be  mistaken  for  a  beginning  pneumonia.  It  clears  up  entirely  in  a  day 
or  two. 

Albuminuria  may  be  met  w^ith  and  occasionally  nephritis.  The 
stomach  and  intestines  are  usually  more  or  less  irritable.  Vomiting  is 
easily  excited  and  diarrhea  not  infrequent.  In  chronic  malaria  there  is 
apt  to  be  constipation. 

Among  other  symptoms  that  may  be  observed  are  headache  and  drowsi- 
ness. Neuralgia  is  frequently  seen.  Multiple  neuritis  of  malarial  origin 
has  been  described,  as  has  also  spasmodic  torticollis. 

Diagnosis. — This  is  best  made  by  an  examination  of  the  blood.  Both 
fresh  and  stained  specimens  should  be  studied.  It  requires  considerable 
practice  to  become  expert  in  the  diagnosis  of  malaria  from  blood  slides. 
If  malaria  is  suspected  repeated  examination  should  be  made.  I  have 
s^en    the    organism    found  after    twenty    or    thirty    trials.     Quinine 


400  INFECTIOUS  DISEASES 

should  not  he  <iiv('n  if  tin-  hlood  is  to  he  examined,  for  it  seems 
to  drive  the  j)arasite  ont  of  the  perijjheral  circidation.  In  tlie  severe 
ea-ses  the  organism  is  nsually  found  on  the  first  examination.  (Quinine 
should,  however,  not  he  withheld  for  any  length  of  time  in  any  severe 
ease  if  ther(>  is  good  reason  to  suspect  nuilaria.  A  fever  which  yields 
promptly  to  (piinine  is  j)rol)al)ly  malaria.  A  fever  which  does  not  yield 
prom|)tly  to  (piinine  is  something  else. 

From  tyi)hoid  fever  the  Widal  agglutination  test  is  of  value. 

In  general  it  may  he  said  that  the  diagnosis  of  malaria  may  be  sus- 
pected from  what  lias  been  said  of  the  paroxysm,  the  fever,  the  anemia, 
the  enlarged  sj)le(Mi,  and  the  cachexia. 

If  the  spleen  cannot  he  felt  in  a  child  some  other  explanation  of  the 
f<'vcr  should  he  sought  for. 

Treatment.  Pioplu/ladic. —Much  can  he  done  in  malarious  districts 
in  doing  awav  with  moscpiitoes  and  in  protecting  children  from  their 
hites.  Drainage  of  marsh  lands  and  the  use  of  j)etroleum  on  the  breed- 
ing places  are  both  efficient.  Screens  in  the  windows  and  doors  of 
houses  or  moscpiito  nets  over  the  child's  crib  should  be  used.  If  out- 
of-doors  at  night  the  face  should  be  covered  with  a  veil  and  the  hands 
with  gloves.  Oil  of  ])ennyroyal,  turpentine,  and  similar  preparations 
mav  be  used  to  keep  ofl"  mos(juitoes. 

flicraprutic. — The  management  of  a  case  of  malaria  is  along  general 
lines.  During  the  chill  warmth  may  be  supplied  or  a  hot  bath  may  give 
relief.  Dtu-ing  the  fever  sponging  with  cool  or  tepid  water,  or  a  cold 
pack  and  an  ice-cap  to  the  head  may  be  used.  The  convidsion  some- 
times seen  should  be  treated  symptomatically.  The  specific  treatment 
is  the  administration  of  (piinine.  The  dose  should  be  relatively  larger 
than  that  for  adults.  Children,  a.s  a  rule,  bear  quinine  very  well.  Some- 
times it  may  upset  the  stomach  and  in  older  children  it  may  cause 
tiimitus.  For  very  y<>"ng  infants  the  sulphate  of  (piinine  maybe  given 
in  O.Oii  gm.  (\  gr.)  doses  every  three  hours.  At  a  year  of  age  0.06 
gm.  (1  gr.)  may  be  given  every  two  or  three  hours,  and  at  two  years 
O.bS  gm.  (2  gr.)  may  be  given.  A  child  of  six  or  over  maybe  given 
much  larger  doses.  The  plan  of  giving  a  large  dose  several  hours  before 
the  expected  paroxysm  is  not  of  much  use  in  young  children,  as  it  is 
likely  to  disturb  the  stomach.  If  even  the  smaller  doses  at  regular 
intervals  cause  vomiting  it  may  be  given  on  an  empty  stomach,  as  at 
night,  and  then  omitted  during  the  day  while  the  child  is  taking  food. 
If  it  is  persistently  vomited  twice  the  ordinary  doses  may  be  given  per 
rectum,  either  in  solution  or  suppository,  or  it  may  be  given  partly  by 
mouth  and  j)artly  by  rectum.  In  pernicious  cases,  fortunately  rare  in 
children  in  this  country,  and  in  severe  cases  where  quinine  cannot  be 
retained  either  by  mouth  or  rectum,  it  may  be  given  subcutaneously. 
This  should  never  be  done  except  when  absolutely  necessary,  as  it 
causes  a  great  amount  of  local  irritation  and  luay  cause  sloughing  or 
abscesses.    "^Fhe  strictest  aseptic  precautions  should  be  used. 

The  quinine  should  be  kept  up  until  the  paroxysms  cease  and  the 
temperature  reaches  normal,  which  it  usually  does  promptly.      After  that 


MALARIA  461 

smaller  doses  in  the  most  palatable  form  should  be  administered  for 
several  days  or  a  week. 

In  severe  cases  it  is  not  well  to  trust  to  any  of  the  various  tasteless 
substitutes,  but  to  use  one  of  the  salts  of  the  alkaloid,  as  the  sulphate  or 
the  bisulphate.  For  older  children  capsules  may  be  used.  Pills  should 
not  be  given.  For  younger  children  the  bisulphate,  which  is  soluble  in 
about  ten  parts  of  water,  may  be  used.  The  taste  is  best  disguised  by 
using  elixir  glycyrrhizie  or  the  elixir  eriodictyi  aromaticum  (yerbasanta), 
the  syrup  of  orange  or  the  syrup  of  sarsaparilla.  The  sulphate  may  be 
suspended  in  any  of  the  above  just  before  giving  the  dose.  If  it  stands 
it  will  partially  dissolve  and  cause  a  very  bitter  mixture. 

For  infants  the  plain  solution  of  bisulphate  and  water  usually  answers 
best  and  is  less  apt  to  upset  the  stomach.  In  less  severe  cases  and  for 
use  after  an  attack  the  less  effective  but  more  palatable  forms  may  be 
recommended.  There  are  syrups  of  cinchona,  alkaloids,  or  so-called 
tasteless  quinine.  The  dose  varies  with  preparation;  usually  a  tea- 
spoonful  represents  0.13  gm.  (2  gr.)  suspended  in  syrup.  Euquinine, 
dose  same  as  the  sulphate,  is  tasteless  and  only  slightly  soluble  in  water; 
tannate  of  quinine,  dose  0.06  to  0.9  gm.  (1  to  15  gr.),  insoluble  and 
tasteless,  generally  given  in  chocolate  tablets,  which  usually  contain 
0.06  gm.   (1  gr.). 

For  rectal  use  the  bisulphate  or  the  sulphate  may  be  made  more 
soluble  by  means  of  tartaric  acid;  0.16  gm.  (2^  gr.)  of  the  acid 
are  used  for  each  0.9  gm.  (15  gr.)  of  quinine.  This  dissolved  in 
2  teaspoonfuls  of  water  and  the  proper  amount  added  to  barley-gruel  is 
given  as  a  high  rectal  injection.  Rectal  injections  cannot  be  used  very 
often,  as  the  rectum  becomes  very  irritable.  They  should  ordinarily 
not  be  tried  oftener  than  every  six  hours.  Suppositories  of  quinine  may 
be  used.  The  hydrochlorate  or  other  salt  may  be  mixed  with  cocoa- 
butter;  3  drachms  of  cocoa-butter  will  make  12  infant-sized  supposi- 
tories. 

For  hypodermic  use  the  following  is  the  formula  of  Bacelli,  who  also 
recommends  this  for  intravenous  injection: 

P:— Quinin.  bimuriat 1.00  gm.  (gr.  xv). 

Sodii  chloridi 0.06    "  (gr.  j). 

Aq.  destil 10.00  c.c.  (3iiss).— M 

If  this  is  not  at  hand  the  following  may  be  substituted: 

P;— Quinin.  bisulphat 1.00  gm.  (gr.  xv). 

Acid,  tartaric 0.15    '•  (gr.  iiss). 

Aq.  destil 10.00  c.c.  (3iiss).— M. 

After  an  attack  of  malaria  the  child  should  be  built  up  by  use  of 
tonics.  Iron,  quinine  and  strychnine  are  the  best.  Arsenic  may  be  given 
in  small  doses,  with  good  result.  In  the  chronic  cases  or  where  there 
are  constantly  recurring  attacks  a  change  to  a  clear,  invigorating  climate 
will  do  more  than  drugs. 


462  INFECTIOUS  DISEASES 

EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

By  D.J.  McCAlMHY,  M.D. 

This  form  of  meningitis  is  <lue  to  a  specific  micro-orf^anism— the 
(liplococcus  intraceUuhiris  meningitidis.  It  occurs  in  epidemics,  but 
sporadic  cases  and  localized  epidemics,  especially  among  children,  are 
not  infreciuent.  Children  are  more  susceptible  than  adults.  The  effect 
of  overexertion,  excessive  heat,  and  bad  hygienic  surroundings  are 
important  factors.  The  disease  is  not  regarded  as  directly  contagious, 
and  is  prevented  in  hospitals  by  simple  antiseptic  precautions  on  the  part 
of  nurses  and  doctors.  Sporadic  cases  are  not  infrequently  met  with  in 
lan'c  cities,  and  may  occur  in  institutions  for  children  with  little  tendency, 
apparentlv,  to  the  production  of  an  epidemic.  P'pidemics  have  been 
more  fri'(|ueiitly  met  with  in  the  countr}'  than  in  cities. 

Pathology. — The  cause  of  the  disease  is  an  encapsulated  diplococcus, 
easily  stained  by  methylene  blue,  and  found  within  the  polynuclear 
leukocytes,  although  it  may  be  free  in  the  cerebrospinal  fluid.  In 
its  morphological  characteristics  it  resembles  the  gonococcus.  The 
brain  and  spinal  cord  are  both  affected  by  the  inflammatory  process. 
In  cases  running  a  very  rapid  course  the  brain  and  spinal  cord  are  very 
red,  due  to  intense  congestion.  If  the  process  lasts  any  length  of  time, 
a  thick,  pussy  exudate  forms  at  the  base  of  the  brain;  in  other  cases 
the  exudate  is  of  a  more  fluid  character  and  covers  the  entire  brain  and 
spinal  cord.  In  the  spinal  canal,  the  lower  portions  of  the  cord,  and 
especiallv  the  posterior  surface,  are  more  intensely  affected.  In  chronic 
cases  the  exudate  becomes  organized  and  results  in  localized  thickening 
of  the  cerei)ral  meninges,  with  involvement  of  the  cranial  nerves. 

The  purulent  process  is  not  only  localized  to  the  meninges,  but  extends 
into  the  brain  substance  with  the  production  of  areas  of  hemorrhagic 
inflammation  and  miliary  abscess  formation.  The  microscopic  exami- 
nation does  not  differ  essentially  from  that  seen  in  other  purulent 
inflammatory  processes;  the  diplococcus  is,  however,  foimd  both  in  the 
exudate  of  the  brain  and  of  the  spinal  cord.  The  diplococcus  may  be 
found  in  the  nasal  or  conjunctival  secretion,  and  it  has  been  a.ssumed 
that  infection  takes  place  in  this  way.  A  pneumonia  may  complicate 
the  disease  and  may  be  due  to  the  pneumococcus  or  the  diplococcus 
intracellularis;  the  complicating  ])neumonia  may  be  either  a  croupous 
pneumonia  or  more  frecjuentiy  in  children  a  bronchopneumonia.  Leu- 
kocytosis is  always  present  in  this  form  of  meningitis. 

Symptoms. — The  symptoms  usually  develop  suddenly  with  vomiting, 
a  chill  f)r  convulsion  and  high  temperature.  The  fever  runs  as  high  as 
104°  to  10.")°  F.,  the  pulse  is  full  and  rapid,  respiration  is  increased,  and 
the  chilfl  is  very  sick.  There  is  evidence  of  intense  headache,  pains 
along  the  spine  and  in  the  back,  with  persistent  projectile  vomiting. 
In   the   beginning   the  restlessness  and   irritability  are  accentuated   by 


PLATE   XII. 


Eruption  of  Cerebrospinal    Meningitis 


EPIDEMIC  CEREBROSPINAL  MENINGITIS  463 

hypersensitiveness  to  light  and  sound.  In  two  or  three  days  these 
symptoms  progressively  increase  until  the  child  becomes  stuporous 
and  then  unconscious.  A  delirium  very  often  supervenes,  usually  of 
an  active  type.  The  irritation  at  the  base  of  the  brain  and  of  the 
spinal  cord  produces  a  stiffness  of  the  muscles  of  the  neck  and  of  the 
back,  with  marked  retraction  of  the  head  and  a  tendency  to  or  actual 
opisthotonos.  The  irritation  of  the  sensory  roots  gives  rise  to  pain  in 
the  extremities  and  a  hyperesthesia  of  the  skin  of  the  body  so  intense 
that  the  slightest  touch  causes  great  suffering.  The  irritation  of  the 
anterior  motor  roots  of  the  spinal  cord  produces  spasms  of  a  chronic 
or  a  tonic  type  in  the  extremities  and  the  face.  The  irritation  of  the 
motor  nerves  at  the  base  of  the  brain  produces  strabismus,  grinding 
movements  of  the  jaws  associated  with  dilatation  of  pupils,  and  the  loss 
of  reaction  to  light. 

About  the  third  day,  but  sometimes  later  than  this,  an  eruption 
appears  over  the  entire  body.  The  typical  eruption  is  a  series  of 
petechial  spots  immediately  beneath  the  skin,  which  do  not  disappear 
on  pressure.  Other  hemorrhages  deeper  in  the  tissues  produce  a  purplish 
mottling  here  and  there.  In  an  epidemic  which  I  recently  studied  an  ery- 
thematous rash  was  present  in  a  large  number  of  the  cases.  In  some 
cases  there  may  be  no  eruption  whatever.  Herpes  about  the  lips  and 
sometimes  elsewhere  on  the  body  is  of  frequent  occurrence.  The  tache 
cerebrale  is  readily  produced.  The  bowels  may  be  either  constipated 
or  persistently  loose.  Toward  the  end  of  the  week  convulsions  may 
develop,  the  pulse  becomes  very  rapid,  the  active  delirium  subsides  into 
that  of  the  muttering  type,  and  the  patient  dies  from  febrile  exhaustion 
or  cardiac  failure. 

In  mild  cases  the  fever  is  not  so  high  and  the  irritative  symptoms  less 
intense.  Irritability  and  restlessness,  with  rigidity  of  the  muscles  of  the 
neck  and  of  the  back,  intense  headache,  and  slight  delirium  may  be  the 
only  symptoms  present;  but  even  in  the  mild  cases  the  auditory  or 
optic  nerve  may  be  affected  in  such  a  way  by  the  inflammatory  process 
as  to  result  in  blindness  or  deafness. 

Malignant  cases  sometimes  occur,  running  a  very  rapid  course  and 
ending  fatally  in  two  or  three  days.  The  headache  and  intense  pain 
are  followed  within  twenty-four  hours  by  a  wild  delirium  and  coma, 
convulsions,  retraction  of  the  head,  opisthotonos,  cardiac  failure,  and 
death.  The  fever  may  be  very  high,  but  more  frequently  is  only  of 
moderate  elevation.    The  rash  is  usually  purpuric  in  type. 

The  course  of  the  disease  is  very  variable,  the  temperature  curve  is 
irregular,  and  marked  remissions  in  the  symptoms  may  occur.  A  char- 
acteristic feature  is  the  inequality  of  the  pulse  and  temperature.  The 
pulse  is  irregular  and  it  may  be  low  when  the  temperature  is  high. 

Death  may  occur  at  any  time  during  the  disease  from  cardiac  failure, 
pneumonia,  arthritis,  cystitis,  or  grangrenous  bed-sores.  In  cases 
which  go  on  to  recovery  (and  cases  exhibiting  the  most  intense  symp- 
toms at  times  recover)  an  exhausted  and  asthenic  condition  persists 
for  a  long  time.     The  patients  remember  nothing  of  what  has  happened 


464  INFECTIOUS  DISEASES 

(lurin<x  thv  roursc  of  the  disease,  show  little  interest  in  what  is  takin<]f 
|)l;i(v  about  tluMU,  often  fail  to  reeof^nize  their  elosest  relatives,  and 
make  little  effort  to  talk  or  eare  for  themselves.  In  some  eases  it  may 
be  several  weeks  or  even  months  before  an  approaeh  to  the  normal 
mental  or  physieal  condition  is  manifest.  The  sequela^  are  often  very 
serious.  Chronic  hydrocephalus  with  marked  mental  deficiency  may 
result  in  infants  from  the  exudate  at  the  base;  even  where  this  does 
not  occur  paroxysms  of  severe  headache  or  of  pain  in  the  extremity 
may  persist  for  a  long  time.  Deafness  often  occurs  and  usually  results 
in  children  in  deaf-mutism.  About  one-fifth  of  all  cases  of  deaf-mutism 
are  occasioned  by  tiiis  disease.  Blindness  may  follow  a  neuritis  of  the 
o|)tic  nerve  or  a  septic  process  in  the  eye  itself. 

Prognosis. — The  mortality  varies  greatly  in  different  epidemics  and 
may  range  from  20  to  75  per  cent.  In  the  sporadic  cases  prognosis 
should  always  l)e  guarded,  but  can  usually  be  made  toward  the  end  of 
tlu'  first  W(>ek  l)y  the  intensity  of  the  symptoms  presented  at  this  time. 
A  violent  onset  with  convulsions  generally  indicates  a  severe  type  of 
infection  and  a  fatal  result  may  be  expected.  A  rapidly  developing 
coma  early  in  the  progress  of  the  disease  is  of  bad  prognostic  omen. 
A  diminution  of  the  leukocytosis,  while  not  of  definite  prognostic 
import,  may  be  regarded  as  favorai)le.  The  prognosis  must,  however, 
always  be  guardecl. 

Diagnosis.^When  the  disease  occurs  in  epidemic  form  the  diagnosis 
even  of  the  mild  cases  is  comparatively  easy.  There  is,  however, 
greater  difficulty  in  the  sporadic  cases.  The  symptoms  present  do 
not  differ  (\ssentially  from  those  of  other  forms  of  meningitis.  When, 
therefore,  a  ciise  of  meningitis  occurs,  for  which  no  possible  source 
of  infection  can  be  found,  the  possibility  of  epidemic  cerebrospinal 
meningitis  should  always  be  considered.  In  typical  cases  where  a 
rash  is  present  a  j)ositive  diagnosis  may  be  made  from  the  symptoms 
alone.  In  all  other  cases  it  must  depend  upon  an  examination  of  the 
cerebrospinal  fluid  (p.  382).  The  fluid  obtained  may  be  perfectly  clear 
in  the  earlier  stages  and  in  mild  cases,  or  it  may  be  cloudy  and  bloody  or 
purulent.  Cover-slip  preparations  should  be  made  and  carefully  studied 
by  selective  stains  not  only  for  the  diplococcus  intracellularis,  but  also 
for  the  dij)l()coccus  pneumonia'  and  the  l)acillus  tuberculosis.  Where 
a  differential  diagnosis  of  tuberculous  meningitis  is  in  question  the 
fluid  may  be  injected  into  a  guinea-pig  to  secure  more  accurate  results. 
From  typhoid  fever  the  results  of  spinal  puncture  and  Widal  reaction 
are  sufficient. 

Recently,  1  was  asked  to  see  two  cases,  susj)ect(>d  to  be  cerebrospinal 
meningitis,  in  a  large  institution  for  orphan  children.  Both  children  had  a 
temperature  ranging  from  100°  to  1(31°  F.,were  very  restless,  irritable, 
and  paralyzed  in  the  lower  extremities.  There  was  no  evidence  of  head- 
ache, no  retraction  of  the  neck,  no  rigidity  of  the  spinal  muscles,  and 
no  Kernig  symptom,  l)ut  there  was  distinct  evidence  of  enlargement 
of  the  epiphyses  of  the  long  bones,  a  beginning  rachitic  rosary,  and 
profuse  sweating  about  the  head  and  neck.     A  diagnosis  of  ])seudo- 


INFLUENZA 


465 


paralysis,  of  rickets  and  scorbutus  was  made  with  a  favorable  prog- 
nosis. Both  cases  recovered  from  the  acute  symptoms  after  several 
weeks  of  treatment  directed  to  the  correction  of  diet. 

Treatment.— The  general  treatment  is  the  same  as  that  for  other 
forms  of  meningitis,  i.  e.,  symptomatic.  While  this  form  is  not  known  to 
be  definitely  contagious,  it  is  a  wise  precaution  to  isolate  the  patient  in 
charge  of  a  trained  nurse.  The  room  should  be  quiet  and  dark.  The 
bowels  must  be  kept  open  and  the  bladder  must  not  be  allowed  to 
become  distended.  Irrigation  of  the  nose  and  nasopharynx  with  nor- 
mal salt  solution  will  lessen  the  dryness  of  the  membrane  and  wash 
away  secretions  of  mucopus.  Aufrecht  and  others  have  obtained  good 
results  from  the  use  of  the  tub  bath  at  98°  to  104°  F.,  repeated  as  often  as 
every  three  hours.  Lumbar  puncture  apart  from  its  diagnostic  value  may 
in  some  cases  relieve  pressure  symptoms,  and  in  this  way  produce  good 
results.  In  recent  epidemics  the  antitoxins  used  in  other  infections, 
and  especially  the  antitoxin  of  diphtheria,  have  been  much  lauded  as 
having  curative  properties.  There  is  no  reason,  from  a  scientific  stand- 
point, why  they  should  have  any  eifect.  There  is  no  reason,  on  the 
other  hand,  why  they  should  not  be  used.  Inasmuch  as  even  severe 
cases  of  this  disease  recover  under  the  symptomatic  treatment,  it  is 
difficult  to  decide  how  much  value  there  is  in  empirical  serum  therapy. 
A  specific  antitoxin  for  the  diplococcus  intracellularis  should,  theo- 
retically, give  good  results  in  cases  that  have  not  advanced  to  destruc- 
tion of  nervous  tissue.  Trephining  has  been  used  in  a  few  cases,  but 
the  results  claimed  for  it  can  only  be  due  to  the  relief  of  the  pressure 
symptoms.  Lysol  and  other  agents  have  been  injected  into  the  dural 
canal  without  definite  results.  The  treatment  has  been  well  summed 
up  by  Huber^  as  "necessarily  empirical  and  symptomatic." 

INFLUENZA. 

By  MATTHIAS  NICOLL,  Jr.,  M.D. 

Pandemics  of  Influenza,  or  Grip  (la  Grippe),  have  been  described  for 
many  centuries :  the  last  severe  one  began  in  1889,  and  spread  quickly 
over  the  whole  world.  Following  such  an  epidemic  local  outbreaks 
continue  to  appear  at  intervals  for  many  years,  occurring  most  fre- 
quently in  the  winter  and  spring. 

The  number  of  cases  occurring  among  children  varies  in  different 
epidemics.  In  some  they  are  more  frequently  attacked  than  adults. 
At  no  age  is  there  immunity  to  the  disease.  Children  under  one  year 
are  relatively  immune,  especially  nurslings  under  six  months,  although 
influenza  has  been  observed  even  in  the  newborn  where  mothers  have 
contracted  the  disease  before  confinement. 

Bacteriology. — The  specific  germ  was  described  by  Pfeiffer  from 
observations  made  during  epidemics  above  referred  to.     Certain  pecu- 

1  Archives  of  Pediatrics,  May,  1905,  p.  338. 
30 


4(i(i  INFECTIOUS  DISEASES 

liarities  of  this  organism  sliould  he  known  in  order  to  understand  the 
various  symptoms  of  the  (hsea^e  and  its  mode  of  propagation. 

It  is  a  very  short,  small  bacillus,  or  elongated  coccus,  found  in  great 
numbers  in  the  bronchial  and  nasal  secretions,  especially  at  the  early 
stages  of  the  disease.  It  grows  readily  on  various  culture  media  to 
which  whole  blood  and  hemoglobin  have  been  added  after  eighteen 
to  thirty  hours'  growth  at  a  temperature  of  37°  C.  (98.6°  F.).  It  forms 
small  colonies  represented  by  glistening  points  on  the  surface  of  the 
media,  which  show  little  tendency  to  coalesce  (Figs.  102  and  103). 

Stained  with  a  10  per  cent,  carbol-fuchsin  solution  the  bacilli  are 
seen  ;us  short,  rather  thick  rods,  varying  greatly  in  dimensions  and 
staining  qualities,  slightly  rounded  at  both  ends,  and  arranged  in 
masses,  or  often  in  short  threads.  They  apparently  do  not  form  spores, 
are  killed  at  a  temperature  of  42°  to  4o°  C.  (107°  to  113°  F.)  and  below 
3°  C.  (26°  to  27°  F. ),  and  very  rapidly  by  drying. 


Fig.  102 


Smears  taken  from  the  nose  and  bronchial  sputum  at  the  early  stage 
of  the  disease  show  the  bacilli  in  enormous  numbers,  at  first  free  and 
not  associated  with  other  organisms  to  any  great  extent.  Later  they  are 
within  the  pus  cells,  together  with  many  cocci  of  the  pyogenic  variety, 
and  still  later  not  at  all.  They  have  been  found  repeatedly  in  sputum 
of  patients  suffering  from  chronic  pulmonary  conditions,  notably 
tuberculosis,  for  weeks  and  months  apparently  in  a  latent  condition. 

The  influenza  bacillus  shows  a  greater  tendency  to  associate  with 
other  organisms,  especially  pyogenic  cocci,  than  any  other  disease, 
with  the  exception  of  measles  and  scarlet  fever. 


INFLUENZA  467 

At  the  onset  the  symptoms  of  an  attack  of  grip  are  attributable  to 
the  local  action  of  the  Pfeiffer  bacillus  and  the  toxins  elaborated  in 
its  growth.  Very  soon,  however,  if  the  disease  is  protracted  and 
complications  occur,  it  is  due  to  the  action  of  the  associated  organisms 
and  only  indirectly  to  the  grip  bacillus. 

Etiology. — ]\Ian,  of  all  animals,  appears  most  susceptible  to  the  dis- 
ease; indeed,  it  shows  but  little  pathogenicity  for  most  of  the  lower 
animals. 

For  man  it  is  highly  infectious;  the  germ  apparently  enters  by  way 
of  the  nose  or  mouth,  and  extends  rapidly  to  the  respiration  passage 
down  to  the  large  and  medium  bronchi,  and  occasionally  to  the  stomach 
and  intestines.  It  is  apparently  transferred  from  one  person  to  another 
by  means  of  finely  divided  secretions  containing  the  bacilli,  expelled 
by  coughing  and  sneezing,  also  by  the  use  of  towels,  handkerchiefs, 
and  fingers  on  w^hich  the  bacilli  have  lodged  in  a  moist  state.     The 

Fig.  103 


V-**"         •  •     /■'     -  ' 


Influenza  bacilli  X  1000.    Eighteen-hour  culture  stained  with  carbol-fuchsin. 

possibility  of  transmission  by  means  of  letters,  books,  and  goods  from 
a  distance  has  been  held  responsible  for  the  spread  of  the  disease  to 
widely  separated  localities.  This,  however,  has  not  been  substantiated, 
and  from  what  has  been  said  of  the  readiness  with  which  they  succumb 
to  drying  does  not  seem  tenable.  The  bacillus  shows  little  or  no  ten- 
dency to  invade  the  blood  or  lymph  stream. 

Influenza  is  a  disease  whose  symptoms  are  largely  made  up  of  cornplica- 
tions  caused  by  other  organisms.  During  the  prevalence  of  an  epidemic 
its  recognition  is  not  difficult  under  ordinary  circumstances.  Spas- 
modic cases  are  often  mistaken  for  other  pathogenic  conditions,  and 


468  INFECTIOUS  DISEASES 

vice  vcr,sa,  the  diagnosis  of  grip  being  all  too  connnonly  made  in  the 
eiise  of  ordinary  colds  accompanied  hy  coryza,  and  ohscnre  fel)rile 
conditions  of  many  kinds.  Bacteriological  examination  has  not  heen 
frecpiently  made  as  a  matter  of  routine,  and  although  the  direct  method 
of  examination  does  not  present  any  great  difficulties,  unless  made  at 
an  early  stage,  it  is  apt  to  give  negative  results. 

Pathology. — -There  seems  to  he  no  characteristic  pathogenic  change 
due  to  intiuenza.  The  nnicous  memhranes  atiected  show  swelling  and 
marked  congestion  and  catarrhal  inflammation;  the  neighboring  lym- 
phatic structures  often  show  congestion  and  hyperplasia.  The  spleen 
may  be  involved  and  also  Fever's  ])atches. 

Symptomatology. — When  the  disease  att'ects  children  above  five  years 
of  age  it  (litfcrs  very  little  from  the  well-known  .symptoms  .seen  in  adults. 
Younger  children  present  certain  peculiarities  in  symptoms,  and  the 
disease  in  infants  is  (|uite  distinctive.  The  incubation  is  very  irregular, 
varying  from  a  few  hours  to  a  week  or  even  longer.  The  invasion  may 
be,  and  usually  is,  abrupt,  or  there  mav  be  symptoms  of  malaise,  loss  of 
appetite,  and  irritability  for  several  days  previous  to  the  invitsion. 

The  disease  may  be  divided  into  several  varieties,  according  to  the 
prominence  of  different  .sets  of  .symptoms. 

The  fchn'lr  form  may  or  may  not  show  a  moderate  coryza.  It  is 
characterized  by  the  presence  of  fever,  usually  high,  and  marked 
toxemia.  The  disease  may  begin  with  a  chill,  rarely  a  convulsion; 
there  is  great  prostration;  older  children  complain  of  headache,  pains 
in  muscles  and  bones,  vomiting  is  frecpient,  and  there  is  complete 
anorexia.  The  fever  may  last  from  twenty-four  to  thirty  hours,  and 
rapidly  subside,  leaving  the  children  weak  and  prostrated,  or  it  may 
run  an  irregular  course  for  several  weeks.  In  severe  cases  so-called 
relapses  may  occur.  There  may  be  an  eruption  on  the  body  during 
the  height  of  the  fever.  As  a  rule  this  is  an  erythema,  which  may 
closely  resemble  scarlet  fever,  and  less  closely  and  less  commonly 
measles.     This  is  the  type  of  disease  seen  in  young  infants. 

The  catarrhal  form  of  influenza  is  that  which  is  ol^served  most  fre- 
quently in  older  children.  It  differs  little,  if  at  all,  in  its  .symptoms 
from  the  same  type  as  it  occurs  in  adults.  In  ordinary  cases  the  attack 
comes  on  suddenly,  occasionally  with  a  few  hours  or  even  days  of 
indisposition.  There  is  often  vomiting  or  a  chill  with  acute  coryza, 
followed  by  rapid  invasion  of  the  trachea  and  larger  bronchi.  The 
conjunctivae  are  reddened,  sneezing  and  coughing  are  incessant;  the 
pharynx  shows  more  or  less  intense  congestion,  less  commonlv  a  mem- 
branous process,  due  to  associated  organisms.  The  larynx  may  be 
involved  with  symptoms  of  catarrhal  croup.  If  a  smear  be  made  from 
the  nasal  secretions  or  sputum  at  this  time,  it  will  be  found  to  be  loaded 
with  the  grip  bacilli.  There  is  high  fever,  commonly  headache,  pains 
in  the  joints  and  muscles,  prostration,  a  marked  irritability,  or  somno- 
lence.    The  pulse  is  rapid. 

The  physical  signs  are  those  of  a  bronchitis  of  the  larger  tubes,  less 
often,  in  the  early  stage,  of  the  medium  and  smaller  bronchi;  rales  of 


INFLUENZA  459 

various  kinds  are  scattered  over  the  chest.  The  cervical  lymph  nodes 
may  be  enlarged.  The  fever  may  last  only  a  day  or  two,  when  it  falls 
rapidly,  or  it  may  continue  for  several  weeks.  The  children  are  left 
weak,  anemic,  with  little  or  no  appetite,  and  a  bronchial  cough  which 
may  persist  for  a  long  time,  with  copious  expectoration  of  thick,  sticky 
mucus,  or  one  of  the  many  complications  which  are  associated  with  this 
disease  may  prolong  the  illness  or  even  cause  it  to  terminate  fatally. 

The  gastroenteric  form  of  the  disease  may  occur  in  connection  with 
influenza  afl^ecting  the  membrane  of  the  respiratory  tract  or  as  a  separate 
disease.  There  is  usually  a  rapid  rise  in  temperature,  with  the  symp- 
toms that  occur  with  fever,  a  thickly  coated  tongue,  complete  distaste 
for  food,  and  more  or  less  constant  diarrhea  and  vomiting.  In  the 
severe  form  of  this  type  of  grip  the  fever  continues  for  several  weeks, 
the  stomach  and  intestinal  symptoms  are  grave,  and  the  spleen  may 
be  enlarged.  The  patients  are  markedly  apathetic,  and  the  picture 
is  difficult  to  distinguish  from  that  of  typhoid  fever. 

Cerebral  Influenza. — Any  variety  of  influenza  in  children  old  enough  to 
describe  their  symptoms  may,  and  usually  does,  show  the  effect  of  the 
toxins  on  the  brain.  The  headache  may  be  intense,  the  children  markedly 
apathetic,  less  often  irritable,  the  skin  hyperesthetic,  the  reflexes  in- 
creased; convulsions,  except  in  infants,  are  rare.  In  addition  to  this 
there  is  a  type  of  influenza  which  is  hardly  possible  to  distinguish  clinically 
from  cerebrospinal  meningitis,  save  by  a  bacteriological  examination 
and  the  shorter  course  of  the  disease.  All  the  ordinary  symptoms  of 
meningitis  may  be  present.  True  meningitis  occurring  in  the  course 
of  influenza  or  following  it  will  be  regarded  as  a  complication,  since  it  is 
due  to  associated  organisms,  pyogenic  cocci,  and  pneumococci,  and 
not  directly  to  the  action  of  Pfeiffer's  bacillus. 

Influenza  in  Young  Infants. — In  the  febrile  form  the  symptoms  are 
those  of  high  fever,  rapid  pulse,  and  marked  toxemia.  There  may 
be  vomiting  or  the  disease  may  be  ushered  in  by  a  convulsion.  The 
skin  is  often  covered  with  sweat,  and  an  eruption,  generally  an  erythema, 
is  not  uncommonly  observed.  The  infant  shows  absolute  lack  of  desire 
for  food,  and  usually  lies  in  an  apathetic  condition.  There  is  marked 
hyperesthesia,  and  from  time  to  time  the  patient  may  cry  out  as  though 
in  pain.  The  symptoms  may  last  only  a  day  or  two,  when  they  dis- 
appear with  a  fall  in  temperature,  or  may  last  for  several  weeks,  with 
increasing  emaciation  and  weakness. 

In  the  catarrhal  form  the  picture  is  quite  like  that  of  measles  com- 
plicated by  pneumonia.  There  is  congestion  of  the  upper  air  passages, 
and  later  nasal  discharge.  The  pulse  is  rapid,  the  temperature  high, 
and  the  respiration  is  apt  to  be  very  much  accelerated.  The  physical 
signs  in  the  chest  vary;  they  are  usually  slight  compared  to  the 
severity  of  the  symptoms.  If  present,  they  are  those  of  a  bronchitis 
of  the  larger  tubes.  The  cough  is  persistent.  These  cases  are  frequently 
classed  as  abortive  pneumonia  to  which  the  symptoms  very  closely 
correspond.  The  course  is  usually  short,  the  temperature  very  often 
falling  abruptly  after  twenty-four  to  forty-eight  hours. 


470  INFECTIOUS  DISEASES 

In  the  gastroenteric  cases  the  symptoms  are  those  of  acute  gastro- 
enteric catarrh,  aggravated  by  influenza  toxemia.  There  is  anorexia,  a 
coated  tongue,  somnolence,  prostration,  and  rapid  emaciation.  The 
vomiting  is  persistent,  and  the  diarrhea  may  be  of  a  severe  type,  witli 
high  fever  and  rapid  pulse. 

Complications  and  Sequelae. — These  are  due  in  part  to  the  toxemia 
produced  by  the  Pfeiffer  bacillus,  but  much  more  to  the  action  of  various 
organisms,  notably  the  streptococcus,  staphylococcus,  and  pneumo- 
coccus.  In  infants  bronchopneumonia  is  the  most  frequent  and  dan- 
gerous complication.  Certain  characteristics  of  grip  pneumonia  have 
been  described,  l)ut  it  is  doubtful  if  they  differ  essentially  from  broncho- 
pneumonia secondary  to  other  infectious  diseases.  The  type  most 
commonly  observed  is  that  in  which  there  are  small  areas  of  consoli- 
dation scattered  throughout  the  greater  part  of  both  lungs  with  marked 
involvement  of  the  bronchi,  large  and  small.  When  larger  areas  are 
present  there  is  frequently  a  complicating  pleurisy. 

Lobar  pneumonia  is  not  a  usual  complication  of  influenza  in  children. 
Severe  bronchitis  of  the  smaller  tubes  is  to  be  regarded  as  a  complica- 
tion rather  than  a  part  of  the  disease.  It  is  characterized  by  severity, 
persistence,  and,  in  older  children,  the  presence  of  profuse  expectoration. 

Suppurative  processes,  affecting  the  middle  ear,  not  infrequently 
extending  to  the  mastoid  cells,  of  the  accessory  sinuses  of  the  nose,  of 
the  cervical  nodes,  and  occasionally  of  those  back  of  the  pharynx,  lead- 
ing to  retropharyngeal  abscess,  are  characteristic  of  certain  epidemics. 
Nervous  symptoms  of  various  kinds,  irritability,  mental  depression, 
neuritis,  and  neuralgia  do  not  follow  attacks  of  influenza  in  children  with 
nearly  so  great  frequency  as  in  adults.  Nephritis  occasionally  is  seen  and 
should  not  be  neglected.  In  infants  recovering  from  influenza,  malnu- 
trition and  physical  weakness  may  remain  for  a  long  time.  Marasmus 
occasionally  follows.  Older  children  are  left  very  often  in  a  feeble  state  of 
health,  with  marked  anemia,  loss  of  appetite,  and  diminished  muscular 
power;  they  not  infrequently  become  the  victims  of  tuberculosis. 

Diagnosis. — This  is  not  difficult  during  the  prevalence  of  an  epidemic, 
especially  in  the  case  of  older  children.  In  infants  it  often  presents 
great  difficulties.  In  general,  it  is  based  on  the  presence  of  the  disease 
in  the  locality,  on  the  disproportion  between  the  local  lesions  and  physi- 
cal signs,  and  the  severe  clinical  symptoms.  The  high  fever,  great 
prostration,  rapid  pulse,  and  other  evidences  of  toxemia  serve  to  dis- 
tinguish catarrhal  influenza  from  an  ordinary  cold  and  gastroenteric  influ- 
enza from  other  gastroenteric  disturbances. 

Influenza  pneumonia  is  characterized  by  the  severity  of  the  symptoms, 
the  high  fever  and  rapid  pulse,  absence  of  large  areas  of  consolidation, 
and  consequent  absence  of  marked  physical  signs. 

From  measles  and  scarlet  fever  the  differential  diagnosis  is  based 
on  the  course  of  the  respective  diseases.  From  meningitis,  cerebral 
grip  cannot  be  differentiated  except  by  waiting  for  the  outcome  of  the 
flisease,  and  possibly,  in  the  cases  of  cerebrospinal  and  tuberculous  men- 
ingitis, by  examination  of  the  spinal  fluid  withdrawn  by  lumbar  puncture. 


INFLUENZA 


471 


From  typhoid  fever  the  severe  form  of  enteric  influenza  may  usually 
be  differentiated  by  the  atypical  temperature  of  the  latter,  its  usually 
shorter  course,  absence  of  rose  spots,  and  of  Widal  reaction.  Finally, 
it  is  probable  that  a  more  frequent  examination  of  smears  from  the 
nasal  and  pulmonary  secretions  will  in  many  cases  serve  to  render  a 
probable  diagnosis. 

Course  of  the  Disease  and  Prognosis. — Uncomphcated  grip  in  children 
usually  ends  in  recovery.  Commonly  after  a  short  time  with  the  patient 
left  in  the  feeble  condition  just  described.  In  infants  the  prognosis  in 
uncomplicated  cases  is  good,  but  pulmonary  complications  and  gastro- 
enteric disturbances  so  frequently  occur  that  the  disease  is  in  such 
cases  a  very  serious  one.  Less  often  infants  are  overwhelmed  by  the 
toxemia  of  the  disease  itself. 

Treatment. — There  is  no  specific  for  influenza.  Epidemics  of  the 
disease  are  regularly  followed  by  epidemics  of  quack  remedies.  Each 
case  must  be  treated  according  to  the  symptoms  which  arise. 

The  different  salts  of  quinine  are  quite  universally  regarded  as  hav- 
ing a  favorable  action  on  the  course  of  the  disease.  In  older  children 
they  may  be  given  in  full  doses  provided  the  stomach  is  not  upset  by 
so  doing.  In  infants  they  should  not  be  given.  Stimulants,  especially 
whiskey  and  brandy,  should  be  used  whenever  the  condition  of  the 
pulse  and  evidence  of  great  physical  weakness  require  them.  In  infants 
they  are  often  needed  throughout  the  disease.  To  older  children  in 
order  to  reduce  the  fever  and  act  as  a  nervous  sedative,  phenacetin 
0.06  gm.  (1  grain)  to  each  year  of  the  child's  age  up  to  0.19  to  0.26 
gm.  (3  or  4  grains)  and  repeated  at  four-hour  intervals  if  necessary; 
antipyrin  0.03  gm.  (^  grain)  repeated  are  of  advantage.  The  effect 
on  the  pulse  should  be  carefully  watched;  hyperpyrexia  should  be 
treated  by  means  of  cold  baths,  sponges,  or  packs.  As  in  most  infec- 
tious diseases,  a  brisk  cathartic  is  of  advantage  in  the  beginning.  The 
gastroenteric  form  is  to  be  managed  in  the  same  way  as  gastrointestinal 
attacks  due  to  other  causes.  The  bowels  should  be  cleaned  out  with 
castor  oil  or  calomel,  abstinence  from  food  for  twelve  hours  or  more 
should  be  enforced,  and  the  substitution  of  carbohydrates  for  milk 
until  the  bowels  become  fairly  normal,  when  the  milk  should  be  given 
much  diluted  and  in  small  quantities  or  peptonized 

The  treatment  of  the  pulmonary  complications  is  that  of  broncho- 
pneumonia and  bronchitis  in  general.  Cases  of  influenza  should  be 
isolated  as  carefully  as  possible  from  other  members  of  the  family. 
Infants  especially  should  be  guarded  against  exposure  to  the  disease. 

Suppurative  conditions  of  the  mastoid  cells  and  accessory  sinuses 
of  the  nose  call  for  surgical  interference.  Some  of  the  severe  cases  of 
headache  which  have  followed  grip  have  frequently  been  shown  to  be 
due  to  the  latter  condition  and  prompt  relief  has  followed  the  evacua- 
tion of  pus  and  drainage. 

The  after-treatment  consists  of  the  administration  of  tonics,  espe- 
cially iron  and  cod-liver  oil  and  careful  feeding.  When  these  fail  a 
change  of  climate  will  often  prove  successful  in  restoring  the  health. 


CHAPTER    XVIII. 

^^^^OOPING-COUGH— MUMPS-GLANDULAR  FEVER. 

WHOOPING-COUGH. 

By  MATTHIAS  NICOLL,  Jr.,  M.D. 

Whooping-cough,  or  Pertussis,  is  an  acute  infectious  disease  char- 
acterized by  a  catarrh  of  the  upper  respiratory  system,  hyperesthesia 
of  the  mucous  membrane,  and  more  or  less  frecpient  paroxysms  of 
violent  cough,  succeeded  l)y  a  deep  inspiration  through  a  partly  closed 
glottis,  causing  a  peculiar  "whooj)"  or  "kink." 

While  there  can  be  no  doubt  that  the  disease  is  due  to  a  specific 
organism,  yet  notwithstanding  many  reports  of  its  isolation  there  cannot 
lu'^'said,  at  the  present  writing,  to  be  sufficient  unanimity  among  the 
different  observers  as  to  its  identity  to  justify  the  belief  that  the  specific 
organism  has  yet  been  discovered. 

Mode  of  Infection. — The  disease  is  apparently  transmitted  from  one 
person  to  another  by  means  of  the  breath  or  the  atomized  secretions  from 
the  nose  and  mouth  expelled  by  coughing  and  sneezing.  Fairly  close 
contact  is  essential  for  its  transmission.  Outside  of  the  body  the  organ- 
ism does  not  seem  to  possess  great  vitality;  rooms  which  have  been 
occupied  by  a  whooping-cough  patient  are  apparently  free  from  the 
disease  shortly  after  their  vacation.  Infection  from  the  clothes,  hands, 
etc.,  through  a  third  person  cannot  be  disputed,  but  very  rarely 
occurs. 

Occurrence. — Whooping-t'ough  is  endemic  in  all  large  cities;  in  country 
places  and  in  small  towns  local  epidemics  occur  from  time  to  time. 
The  simultaneous  occurrence  of  measles  has  been  frequently  observed. 
There  seems  to  be  little  difference  in  the  season  as  regards  the  number 
of  cases. 

Age. — The  general  susceptibility  to  the  disease  is  very  great.  At 
no  period  of  life  is  there  immunity.  Children  a  few  hours  old  have 
been  attacked  as  well  as  adults  far  advanced  in  years.  There  is,  however, 
a  great  difference  in  susceptibility  at  different  ages.  From  8.")  to  50  per 
cent,  of  cases  occur  in  children  under  two  years  of  age.  Infants  under 
six  months  and  especially  nurslings  seem  to  possess  a  certain  immunity, 
but  whether  this  is  ac-tual  or  due  to  the  fact  of  their  Ijeing  exposed  less 
frequently  is  not  definitely  determined.  After  the  second  year  the 
number  of  cases  shows  a  marked  falling  oft",  and  diminishes  rapidly 
from  the  fifth  to  the  tenth  year,  after  which  the  disease  is  not  common, 
undoubtedly  due  to  the  fact  that  most  children  over  ten  years  of  age 
(  472  )* 


WHOOPING-COUGH  473 

have  been  rendered  immune  by  an  attack  earlier  in  life.  Girls  and 
boys  contract  the  disease  in  about  equal  proportions. 

Contagion. — Whooping-cough  may  be  conveyed  from  the  very  begin- 
ning of  catarrhal  to  the  second  or  spasmodic  state.  Some  observers 
believe  that  it  is  only  infectious  during  the  catarrhal  period,  basing 
their  opinion  on  hospital  statistics,  where  cases  in  the  spasmodic  stage 
brought  to  cliildren's  institutions  failed  to  convey  the  disease  in  a 
single  instance.  Comby  modifies  this  opinion,  believing  that  the  possi- 
bility of  infection  is  much  greater  in  the  catarrhal  stage,  but  that  during 
the  spasmodic  stage  also  the  disease  may  be  transmitted,  after  which 
the  probability  of  infection  is  remote. 

Pathological  Anatomy. — There  may  be  said  to  be  no  distinctive  patho- 
logical findings  in  uncomplicated  whooping-cough.  There  is  regularly 
found  at  autopsy  in  such  cases  more  or  less  congestion  and  catarrhal 
inflammation  of  the  upper  air  passages,  especially  about  the  larynx  and 
within  the  trachea.  The  lungs  cjuite  regularly  show  more  or  less  emphy- 
sema in  prolonged  and  severe  cases,  especially  at  the  anterior  border 
and  apices. 

Symptomatology.  Course  of  the  Disease. — This  is  usually  divided 
into  three  stages — catarrhal,  spasmodic,  and  stage  of  decline. 

The  Catarrhal  Stage. — After  an  inculcation,  which  varies  from  a  few 
days  to  two  weeks,  the  child  is  attacked  by  what  has  every  indication 
of  being  an  ordinary  cold.  The  eyes  are  moderately  affected;  there  is 
a  catarrhal  rhinitis;  the  pharynx  is  congested.  The  children  are  not 
particularly  ill.  There  may  be  slight  lassitude  and  loss  of  appetite. 
There  is  a  moderate  rise  in  temperature  and  cough.  Various  char- 
acteristics have  been  attributed  to  this  cough,  and  yet,  in  the  great 
majority  of  cases,  it  cannot  be  said  that  they  are  sufficiently  in  evidence 
to  lead  one  to  suspect  the  nature  of  the  disease.  A  paroxysmal  cough 
at  night  is  frequently  observed  at  the  beginning  of  the  pertussis.  The 
physical  signs,  if  any  are  present,  are  those  of  a  bronchitis  of  the  larger 
tubes.  The  cough  shows  no  evidence  of  amelioration,  becoming  more 
constant  from  day  to  day,  and  toward  the  end  of  the  period  taking  on 
a  paroxysmal  character,  even  before  the  appearance  of  the  "whoop." 
The  duration  of  this  stage  is  most  variable;  it  is  usually  placed  as  two 
weeks;  in  some  cases  it  contimies  throughout  the  disease;  in  others, 
especially  in  severe  cases,  it  is  very  short,  and  the  children  appear  to 
whoop  from  the  beginning  of  the  disease.  In  young  infants  the  paroxys- 
mal character  of  the  cough  may  be  present  ahnost  from  the  beginning, 
often  without  the  characteristic  whoop.  Some  of  these  cases  are  not 
easily  detected  early  in  the  disease. 

Spasmodic  Stage. — This  is  characterized  by  the  paroxj'smal  cough 
peculiar  to  the  disease;  the  attack  comes  on  suddenly.  From  adults 
and  children  old  enough  to  describe  their  sensations  it  is  learned  that 
the  premonitory  symptoms  are  a  tickling  or  sense  of  irritation  in  the 
larynx,  producing  an  uncontrollable  desire  to  cough,  and  as  the  spasm 
of  the  glottis  occurs  there  is  a  sense  of  dread  of  impending  suffocation, 
which  the  late  Dr.  O'Dwyer,  having  himself  contracted  the  disease  in 


474  INFECTIOUS  DISEASES 

adult  lite,  describes  as  appalling,  and  as  "though  his  very  last  second 
had   conic." 

The  attack  l)egins  with  a  series  of  cx])losive  expiratory  efforts  follow- 
ing one  another  in  rapid  succession,  no  inspiration  being  taken  between 
them ;  then  a  deep  inspiration  through  the  partly  closed  glottis,  accom- 
panied by  the  characteristic  whoop.  After  a  very  short  time  the  phe- 
nomenon is  repeated;  fre(iuently  several  times,  until  finally  a  plug  of 
nuicus  is  expelled,  when  the  attack  terminates,  often  with  vomiting. 

At  the  approach  of  a  paroxysm  the  child  stops  in  its  play,  runs  to 
someone  as  though  for  relief  from  the  dreaded  sense  of  suffocation. 
Later  in  the  disease,  when  it  has  become  more  or  less  accustomed  to 
the  attacks,  it  seizes  a  chair,  table,  or  side  of  the  bed  as  a  support  during 
the  paroxysm.  While  the  explosive  expirations  are  taking  place,  the 
face  and  head  become  red  or  dusky,  the  conjunctivjc  congested;  the 
eyes  water  and  appear  to  bulge  from  the  socket;  the  nose  runs,  and 
tiie  whole  i)ody  is  drawn  into  a  state  of  spasm,  and  covered  with  sweat; 
the  pulse  is  very  rapid.  With  the  occurrence  of  the  final  whoop  all  the 
muscles  are  relaxed  and  the  chikl  remains  quiet,  in  a  state  of  complete 
exhaustion.  The  number  of  paroxysms  occurring  in  twenty-four  hours 
varies  from  a  dozen  to  eighty  or  a  hundred. 

Many  theories  have  been  advanced  to  explain  the  exciting  cause  of 
the  paroxysm.  It  is  generally  attributed,  and  with  good  reason,  to  the 
plug  of  mucus  in  the  larynx  or  trachea,  presumably  containing  the 
infectious  organism.    After  this  has  been  expelled  the  attack  ceases. 

During  this  stage  there  may  be  a  moderate  rise  in  temperature,  or 
the  disease  may  run  an  afebrile  course.  Its  duration  is  variable,  from 
two  weeks  to  two  months  or  more.  With  every  fresh  cold  the  spasmodic 
attacks  may  be  repeated,  often  after  several  months,  due  apparently  to 
the  hyperesthetic  state  of  the  air  passages  rather  than  to  a  true  relapse. 

Period  of  Decline. — The  spasmodic  attacks  of  the  second  stage, 
having  grown  less  and  less  frequent,  the  whoop  at  last  disappears,  and 
the  disccise  enters  the  third  and  final  stage.  This  is  characterized  by  a 
cough,  having  at  first  something  of  a  paroxysmal  character,  and  gradu- 
ally assuming  that  of  ordinary  tracheobronchitis,  which  continues  for 
two  or  three  weeks  and  ceases.  If  for  a  longer  period  it  is  due,  as  a 
rule,  to  conijilicating  general  bronchitis,  or  other  pulmonary  lesions. 

^  ariations  in  the  usual  type  of  the  disease  occur.  The  course  of  the 
disease  may  be  very  prolonged,  even  without  evidence  of  complication, 
or  it  may  run  a  very  short  course  of  a  week  or  more.  A  cough  at  the 
first  stage  may  disappear,  and  then  suddenly  the  spasmodic  stage  be 
entered  into.  The  disease  may  resemble  a  stubborn  bronchial  cold 
from  the  first,  its  true  character  only  being  recognized  by  the  existence 
of  whooping-cough  in  other  members  of  the  family,  with  characteristic 
symptoms,  or  after  the  disease  has  lasted  for  some  weeks. 

General  symptoms  in  uncomplicated  cases  besides  those  mentioned 
are  the  occurrence  of  leukocytosis,  which  may  be  very  marked.  Albumin 
occurs  in  small  quantities  in  about  half  the  cases,  occasionally  accom- 
panied by  casts. 


PLATE  XIII. 


Subconjunctival  Eeehymosis  in  Whooping-cough. 


WHOOPIXG-COUGH  475 

Complications  and  Sequelae. — The  complications  of  whooping-cough 
may  be  divided  into  those  caused  by  the  mechanical  effect  of  the  spas- 
modic cough  and  those  due  to  infection  by  various  organisms.  To  the 
first  class  belongs  the  ulcer,  covered  with  gray-white  membrane,  seen  on 
the  frenum  of  the  tongue,  or  just  in  front  of  it,  and  caused  by  the  pressure 
of  the  latter  on  the  lower  incisors  during  a  paroxysm.  While  it  is  fairly 
characteristic  of  the  disease  it  occurs  in  other  forms  of  severe  cough. 

Emphysema,  as  already  stated,  regularly  occurs.  It  is  usually  moderate 
in  extent  and  seen  at  the  apex  and  anterior  borders  of  the  lungs.  It 
may  rarely  be  of  a  severe  type,  with  rupture  of  the  lung,  the  formation 
of  pneumothorax,  and  general  subcutaneous  emphysema.  According 
to  O'Dwyer,  emphysema  is  due  to  the  recoil  of  air  against  the  wall  of 
the  pulmonary  vesicle  during  the  forced  expiratory  efforts  through  an 
almost  closed  glottis.  Furthermore,  after  the  lung  has  been  all  but 
emptied  of  air,  that  which  remains  expands,  causing  a  partial  vacuum, 
which  the  subsequent  inspiratory  effort  through  a  partly  closed  glottis 
fails  to  fill,  but,  on  the  contrary,  the  expansion  in  the  chest  tends  to 
increase;  so  that,  according  to  this  view,  both  expiration  and  inspiration 
take  part  in  the  production  of  this  lesion. 

The  increase  in  the  venous  pressure  during  an  attack  leads  very 
frequently  to  hemorrhage,  which  occurs  during  or  following  a  paroxysm 
and  takes  place  most  frequently  from  the  nose,  mouth,  or  trachea. 
Hemorrhages  of  the  conjunctiva  are  not  uncommon  and  give  a  very 
characteristic  picture.  In  addition,  the  cellular  tissue  beneath  the  eyes 
may  be  the  seat  of  hemorrhage  with  the  appearance  of  "black  eyes." 
Hemorrhages  from  the  ears  have  been  frequently  described;  the  drum 
membrane  may  be  ruptured  during  an  attack,  but  usually  this  accident 
occurs  in  a  middle  ear  alreadv  affected  b}^  an  antecedent  disease. 
(See  Plate  XIII.) 

Hemorrhages  into  the  brain  and  pia  mater  are  usually  small,  fre- 
quently multiple,  less  often  large;  they  lead  to  various  paralyses,  disturb- 
ances of  equilibrium,  and  mental  symptoms,  depending  on  their  location. 
Dilatation  of  the  right  heart  to  a  greater  or  less  degree  is  not  uncommon; 
severe  dilatation  with  relative  insufficiency  of  the  valves  has  been 
noted. 

Hernias  may  be  caused  or  increased,  and  prolapse  of  the  rectum  is 
sometimes  noted  with  or  without  the  existence  of  disease  of  the  lower 
bowel. 

Vomiting  occurs  as  a  regular  symptom,  and  may  be  regarded  as  a 
mechanical  result  of  the  cough  unless  it  be  prolonged  beyond  the 
spasmodic  stage. 

Convulsions,  usually  seen  in  young  infants,  are  due  to  intense  cerebral 
congestion  during  an  attack  or  to  intracranial  hemorrhage.  Asph^^a 
may  follow  a  severe  paroxysm,  with  or  without  convulsions. 

The  second  class  of  complications  comprises  those  that  are  caused 
by  infection,  the  most  important  of  which  is  bronchopneumonia,  which 
occurs  much  more  frequently  in  infants  than  in  older  children,  and 
especially  those  in  the  first  year  of  life.     It  is  much  more  often  seen  in 


476  IXFECTIorS  DISEASES 

hospital  cases  anrl  in  tenement-house  practice  than  amid  favorable 
surroundings:  more  often  in  the  winter  and  sprino^  than  the  summer 
months.  It  comes  on  usually  when  the  disease  is  at  its  heifjht,  in  some 
part  of  the  second  sta;,'c.  The  onset  may  he  sudden,  or  there  may  he 
symptoms  for  a  numl)er  of  days  previously  of  a  general  bronchitis. 
The  lesions  consist  usually  of  small  areas  of  pneumonia  scattered  over 
a  fjreater  part  of  both  chests;  or  there  may  be  one  or  more  lart;e  areas 
of  consolidation.  The  re.sj)iration  is  usually  very  rapid  and  out  of  pro- 
jK)rtion  to  the  temjx'rature,  due  to  the  presence,  jx^rhaps,  of  a  conij)!!- 
catint;  emphysema.  The  whoop,  if  it  has  been  present,  often  disapjicars, 
but  the  paroxysmal  character  of  the  cough  usually  remains.  The 
disease  is  very  fatal  and  is  usually  prolonged  even  if  it  terminates  favor- 
ably. Convulsions  frccjuently  occur  during  tiie  course  of  the  pneu- 
monia, or  as  a  final  symptom.  Pleurisy  fretjucntly  complicates  the 
more  chronic  cases. 

Bronchitis  is  a  frequent  complication  in  yoiuig  children,  often  pro- 
longing the  third  stage  of  the  disease. 

Otitis  media  and  mastoid  abscess  are  occasionally  seen. 

In  summer-time  the  disease  in  infants  is  frecjuently  complicated  by 
severe  diarrhea,  which  greatly  ad<ls  to  the  gravity  of  the  case. 

Vomiting,  instead  of  occurring  only  with  the  attacks  of  coughing, 
may  be  almost  incessant  and  continue  far  into  the  stage  of  decline. 
Finally,  any  of  the  infectious  exanthemata  may  and  frequently  do 
complicate  whooping-cough,  especially  in  institutions:  measles  often, 
diphtheria  and  scarlet  fever  not  infrecjuently.  Such  a  complication  is 
very  apt  to  cause  a  fatal  termination. 

Whooping-<-ough  is  not  infrcfjuently  followed  by  general  tul)erculosis, 
the  disease  either  lighting  up  a  latent  process  usually  in  the  bronchial 
lymph  nodes,  or  being  engrafted  on  a  weakened  constitution. 

l\Iarasinus  occasionally  follows  severe  cases  in  infants. 

Dia^osis. — This  is  generally  impossil)le  until  the  stage  of  spasm. 
One  may  suspect  the  nature  of  the  disease  when  a  bronchial  cold  with- 
out any  or  oidy  very  limited  physical  signs  grows  worse  from  day  to 
day  in  spite  of  treatment. 

In  abortive  cases  and  those  without  a  whoop  the  diagnosis  must  be 
made  on  the  other  characteristics  of  the  cough,  history  of  exposure,  and 
absence  of  physical  signs. 

Some  children  whooj)  to  a  moderate  extent  whenever  they  contract 
cold,  but  the  character  of  the  cough  is  not  typical  and  the  course  of  the 
disease  is  rjuite  different  from  that  of  whooping-cough.  Such  children 
frequently  have  adenoid  growths  or  a  thickened  pharvnx. 

Foreign  bodies  in  the  larynx  have  occasionally  simulated  this  disease 
and  led  to  a  false  diagnosis. 

Enlarged  bronchial  lymph  nodes  pressing  on  the  pneumogastric  nerve 
give  rise  to  symptfims  in  some  cases  hardly  to  l)e  differentiated  from 
those  of  whooping-cough.  The  course  of  the  two  diseases,  method  of 
onset,  history  of  exposure,  must  be  taken  into  account  in  determining 
the  nature  of  the  case. 


WHOOPING-CO  UGH 


477 


Prognosis. — The  aggregate  mortality  from  whooping-cough  is  large, 
as  the  following  statistics  quoted  by  Comby^  will  show.  In  the  city  of 
Paris,  from  1880  to  1900,  7613  deaths  occurred  from  the  disease.  In 
the  city  of  London  in  1893,  2330  deaths.  According  to  Johnston,' 
whooping-cough  in  the  United  States  is  responsible  for  the  deaths  of 
100,000  children  in  every  decade. 

It  is  a  much  more  fatal  disease  in  institutions  and  in  poor  surround- 
ings than  when  occurring  under  opposite  conditions. 

Age  is  a  most  important  factor  in  determining  the  outcome.  In 
children  under  two  years,  and  especially  those  under  one  vear,  it  is 
very  fatal  on  account  of  the  occurrence  of  complications,  especially 
of  pneumonia  and  convulsions.  After  two  years  the  death  rate 
gradually  decreases,  and  after  five  it  is  very  low.  The  prognosis  is  not 
as  good  in  winter  as  in  summer  or  in  rachitic  and  debilitated  children 
as  in  those  previously  in  good  health.  It  is  not  good  when  constant 
vomiting  interferes  with  the  patient's  nutrition  or  when  the  disease  is 
complicated  by  one  of  the  exanthemata. 

The  severity  of  any  uncomplicated  case  is  to  be  judged  by  the  number 
of  paroxysms  occurring  in  twenty-four  hours,  together  with  the  violence 
and  duration  of  the  individual  seizures. 

Treatment. — The  number  of  remedies  suggested  for  whooping-cough 
bears  eloquent  testimony  to  the  lack  of  success  attending  any  one  kind 
of  treatment,  and  yet  a  great  deal  can  be  accomplished  in  alleviating 
the  sufferings  of  the  patient,  even  though  the  course  of  the  disease  is 
not  altered. 

General  Measures. — When  the  nature  of  the  disease  has  been  deter- 
mined the  child  should  be  isolated  in  so  far  as  possible  from  susceptible 
individuals  and  especially  from  young  infants.  The  food  should  be  easy 
of  digestion,  peptonized  if  necessary.  The  children  may  be  required  to 
be  fed  at  frequent  intervals  if  the  vomiting  is  constant.  Milk  forms  a 
suitable  diet  in  many  cases.  In  artificially  fed  infants  it  may  have  to 
be  weakened  or  predigested. 

There  can  be  no  doubt  that  these  patients  cough  much  less  when 
out-of-doors  than  when  confined  to  a  closed  room,  for  which  reason  they 
should  be  allowed  out  on  good  days  as  much  as  possible,  the  room  being 
thoroughly  aired  and  cleaned  before  their  return.  In  inclement  weather, 
room  airings  may  be  substituted.  If  it  is  necessary  to  confine  the  child 
to  one  or  two  rooms  they  should  be  aired  and  cleaned  constantly. 
Frequent  change  of  bed-clothes  and  wearing  apparel  are  helpful.  In 
severe  cases  which  do  not  yield  to  ordinary  measures,  a  change  to 
a  warm  climate,  preferably  by  the  open  sea,  or  a  sea  voyage,  is  often 
of  great  benefit. 

The  milder  attacks  of  whooping-cough,  especially  when  occurring  in 
children  over  two  years  of  age,  require  no  other  treatment  than  careful 
feeding,  proper  clothing,  and  fresh  air. 

1  Traits  des  maladies  de  I'enfant. 

2  Medical  Society  of  the  District  of  Columbia,  January  23, 1895. 


478  INFECTIOUS  DISEASES 

No  mnecly  lias  yet  been  discovered  which  has  a  uniform  effect  in 
sliortenint;  tlie  disease,  hut  many  (hminish  the  numl)er  and  severity  of 
tlie  spasms  in  a  certain  proportion  of  cases.  A  few  of  those  which  liave 
been  found  most  efficacious  are  as  follows: 

Local  Treatment. — This  consists  of:  1.  Insufflation  of  various  powders 
into  the  nose  and  larynx;  quinine  mixed  with  some  bland  powder,  as 
bicarbonate  of  soda  or  acacia,  in  the  pro])()rtion  of  1:10  or  stronger; 
antipyrin,  boric  acid,  and  l)enzoin,  the  treatment  being  given  three  or 
four  times  a  day,  preferably  just  after  a  spasm.  This  method  of  pro- 
cedure is  at  present  but  little  in  vogue.  Its  results  are  far  from  con- 
vincing. 

2.  Apj)lications  to  the  larynx,  especially  of  cocaine  solutions,  1  to  4 
per  cent.,  is  undoubtedly  efficacious,  but  it  is  a  (Hfficult  method  of 
treatment  and  the  danger  of  poisoning  must  be  borne  in  mind.  Weak 
solutions  of  1 :  00  and  1 :  00  of  carbolic  acid  and  other  antiseptics  may 
be  also  used  in  this  way. 

•S.  Inhalations  of  carl)olic  acid,  creosote,  and  cresolin  have  been  found 
of  decided  benefit.  The  air  of  the  room  may  be  saturated  with  one  of 
these  substances  by  means  of  a  croup  kettle  or  special  apparatus  made 
for  this  purpose,  or  clothes  soaked  in  carbolic  acid  may  be  hung  over 
the  children's  Ix'd,  or  the  substances  used  in  an  inhaler.  The  possi- 
bility of  carbolic  acid  poisoning  is  to  be  guarded  against  by  regular 
examination  of  the  urine. 

The  treatment  suggested  by  Bergeon  in  bS87,  and  later  used  with 
marked  success  by  Dr.  O'Dwyer  in  the  New  York  Foundling  Hospital 
in  the  treatment  of  150  cases  of  whooping-cough,  consists  of  the  rectal 
administration  of  carbonic  acid  gas.  For  this  purpose  there  is  needed 
a  wide-mouthed  bottle  holding  a  pint  or  more,  into  which  passes  a 
glass  tube  through  a  perforated  cork.  A  rectal  tube  is  fitted  to  this 
with  a  nozzle  suitable  for  introducing  into  the  rectum.  The  bottle 
is  filled  one-third  with  water  and  24  gm.  (6  dr.)  of  bicarbonate  of 
soda  dissolved  in  it,  after  which  15.50  gm.  (h  oz.)  of  crystalline  tar- 
taric acid  is  added  and  the  rectal  tube  inserted.  COj  is  thus  liberated 
in  proper  quantities.  The  treatment  is  continued  for  five  to  ten  minutes, 
depending  on  the  child's  age,  and  given  three  times  a  day.  A  flushing 
of  the  face  regularly  follows  the  administration  of  the  gas.  The  par- 
oxysms are  reduced  in  number  and  the  whoop  often  promptly  disappears, 
together  with  the  vomiting.  Occasionally  the  treatment  will  have  to 
be  suspended  on  account  of  the  occurrence  of  a  mild  diarrhea.  While 
I  have  had  no  personal  experience  with  this  form  of  treatment,  the  fact 
that  it  has  })een  vouched  for  by  so  good  an  observer  justifies  its  fiu'ther 
use,  especially  as  it  produces  no  dangerous  symptoms.  The  breathing 
of  the  gas-laden  air  of  gas  tanks  is  in  all  probability  a  popular  mode 
of  applying  this  treatment. 

For  the  immediate  relief  of  threatened  suffocation,  or,  in  order  to 
abort  a  spasm,  pulling  the  jaw  forward,  as  suggested  by  Naegeli  and 
lately  by  Sobel,  is  effective  in  a  certain  number  of  cases.  The  admin- 
istration of  chloroform  or  ether  or  the  inhalations  of  oxygen  is  occa- 


WHOOPING-COUGH  479 

sionally  indicated.  Finally,  intubation  has  been  practised  with  more 
or  less  success,  in  this  countiy  and  Europe,  in  desperate  cases. 

Internal  Treatment. — Among  the  large  number  of  remedies  suggested 
the  following  have  stood  the  test  of  time  and  experience  as  being  effi- 
cacious in  a  good  proportion  of  cases.  Antipyrin,  well  borne  by  even 
young  infants  in  doses  of  0.06  gm.  (1  gr.)  to  each  year  of  a  child's 
life  up  to  0.2  gm.  (3  gr.),  every  two  hours.  The  addition  of  sodium 
bromide  in  quantities  double  that  of  antipyrin  has  seemed  to  me  to 
increase  the  efficacy  of  this  method  of  treatment.  In  older  children 
quinine  in  doses  of  0.13  to  0.19  gm.  (2  or  3  gr.)  of  the  sulphate  or 
its  equivalent,  three  times  a  day,  is  well  thought jof  by  many.  It  may 
be  given  in  syrup  of  yerba  santa.  When  it  upsets  the  digestion,  which 
it  is  apt  to  do,  it  should  be  discontinued,  and  on  no  account  should  it 
be  given  to  infants. 

Belladonna,  pushed  to  the  point  of  tolerance,  undoubtedly  has  an 
effect  on  the  symptoms.  Its  routine  employment  is  more  or  less  hmited 
to  hospital  cases  and  those  which  are  constantly  under  skilled  observa- 
tion. The  fluid  extract  may  be  given  in  doses  of  0.032  c.c.  {\  min.) 
every  four  hours  and  gradually  increased,  or  the  intervals  shortened. 
Flushing  of  the  skin  and  dilatation  of  the  pupils  must  be  induced  in 
order  to  secure  the  benefits  of  this  drug. 

A  remedy  suggested  to  me  by  Dr.  Silver,  of  the  Vanderbilt  Clinic,  in 
New  York,  and  employed  very  frequently  since,  has  produced  good 
resiilts  in  a  majority  of  the  cases  in  which  it  was  used,  namely,  the 
internal  administration  of  peroxide  of  hydrogen  (3  percent.),  as  in  the 
following  prescription : 

P?.— Hydrogen  peroxid 60.0  c.c.  (Sij). 

GlyceriDum 15.0  "  (gss). 

Aquse q.  s.  ad  120.0   "  (giv).— M. 

Sig. — Teaspoonful  in  water  every  two  hours. 

No  bad  results  have  followed  this  treatment,  and  the  number  of 
paroxysms  and  their  severity  have  been  regularly  reduced. 

Bromoform  may  be  mentioned  as  having  had  many  advocates  at 
one  time;  poisoning  has  been  reported  in  a  number  of  instances.  It 
may  be  given  in  doses  of  0.18  to  0.30  c.c.  (3  to  5  min.)  three  times 
a  day,  or  more  frequently,  the  initial  dose  being  about  0.06  c.c.  (1  min. 
for  a  child  of  one  year.  It  should  never  be  given  in  a  mixture  that  is 
allowed  to  stand  or  that  is  not  well  shaken. 

Treatment  of  Complications. — Vomiting  which  persists  after  the 
spasmodic  stage  may  require  the  temporary  employment  of  rectal  feed- 
ing or  stomach  washing,  in  addition  to  the  use  of  readily  digested  food 
in  small  quantities  at  frequent  intervals.  For  diarrhea  and  intestinal 
catarrh  the  usual  treatment  is  to  be  employed:  cathartics  at  the  outset, 
castor  oil  or  calomel,  stopping  the  milk,  and  the  substitution  of  carbo- 
hydrates, broths,  soups,  and  chopped  meat,  together  with  lavage  of  the 
bowels  when  necessary. 

Hemorrhage  cannot  be  prevented  except  by  control  of  the  paroxysms. 
In  severe  epistaxis  astringents  may  be  tried,  as  douches  or  the  local 


480  INFECTIOUS  DISEASES 

aj)})li('ati()ii  of  iidrcnalin,  I  :.')()()()  (o  1  :  l(),()()l)  solution,  and,  as  a  last 
resort,  j)lMiji;<:;iM;:;  tlic  |)ostc'rior  iiaivs. 

Stiimilaiits  arc  urcilcd  in  cases  of  weak  heart  and  in  most  infants. 

Bronelu)j)neuni()nia  eoniplicatin",^  \vliooj)inii;-cou^li  is  to  he  treated  in 
the  same  way  a.s  pneumonia  eomplieating  other  infections  tliseases,  but 
needs  very  careful  oversight  because  of  the  paroxysmal  cough. 

In  institutions  for  children  when  di])htheria  j)rcvails  innnunizing 
doses  of  antitoxin  should  be  given  at  the  onset  of  the  disease. 

The  after-treatment  consists  of  cod-liver  oil,  syruj)  of  the  iodide  of 
iron,  etc.,  attention  to  the  diet  and  general  health,  and,  when  possible, 
chantre  of  climate. 


MUMPS. 
By  MATTHIAS  NICOLL,  .Tr.,  M.D. 

Mumps  (Infectious  Parotitis)  is  an  acute  coinmunicable  disease  char- 
acterized by  swelling  of  the  salivary  glands  and  tendency  to  involve 
other  glandular  structures,  notably  those  of  the  genital  tract. 

Occurrence. — The  disease  in  children  occurs  most  fre(juently  between 
the  age  of  five  and  fifteen  years,  though  it  is  occasionally  met  with  at 
a  nnich  earlier  period.  It  occurs  in  small  epidemics,  especially  in 
schools  and  other  institutions  where  older  children  congregate.  At 
the  New  York  F'oundling  Hospital,  in  which  nearly  all  the  children 
are  under  five  years  of  age,  the  disease  is  practically  unknown. 

Etiology. — Close  contact  is  necessary  for  its  dissemination,  which  is 
probably  through  the  agency  of  the  breath.  It  may  rarely  be  conveyed 
by  a  third  person,  clothes,  and  other  articles. 

It  is  apj)arently  contagious  from  the  very  beginning  of  the  symptoms 
to  the  time  of  subsidence  of  the  glandular  swelling,  and  even  later. 

One  attack  usually  renders  a  patient  innnune  during  the  rest  of  life, 
but  second  attacks  are  not  very  rare  and  relapses  occasionally  occur. 

Incubation. — Cases  have  been  reported  as  occurring  one  week,  or 
even  less,  after  exposure.  The  usual  period  of  incubation  is  a  long  one, 
usually  from  eighteen  days  to  three  weeks  or  more. 

Bacteriology. — ^A  diplococcus  isolated  by  Laveran  and  Catrin  from 
the  blood,  testicles,  and  serous  effusions  occurring  in  the  course  of  the 
disease  has  been  identified  l)V  other  observers,  and  while  much  evidence 
points  to  it  as  the  specific  cause,  thus  far,  to  my  knowledge,  no  one  luis 
succeeded  in  r<'j)rodncing  the  disease  by  inoculating  cultures  of  the 
organism. 

Pathology. — In  the  rare  cases  which  have  been  brought  to  autopsy 
there  hjis  l)een  found  congestion  of  the  gland  involved,  with  catarrh  of 
the  tubules  and  edema  of  the  surrounding  connective  tissues.  In 
com])licating  orchitis,  evidence  of  atrophy  of  the  seminiferous  tubules 
has  been  described. 

Symptomatology. — In  many  cases  there  are  no  prodromata,  or  these 
are  so  slight  that  the  first  symptom  noted  is  the  swelling  of  the  parotid 


MUMPS 


481 


gland.  There  is  usually  a  rise  in  the  temperature  of  two  or  three 
degrees. 

In  other  cases  the  fever  is  high  and  accompanied  by  headache,  pain 
in  the  back  and  muscles.  There  is  loss  of  appetite  and  general  languor. 
There  may  be  chilly  feelings  or  an  actual  chill.  Cases  of  delirium  have 
been  described.  The  more  violent  method  of  onset  is  much  more 
commonly  seen  in  adults  than  in  children.  Other  symptoms  frequently 
complained  of  are  sore  throat  and  earache.  Epistaxis  may  usher  in 
an  attack. 

The  swelling  of  the  gland  begins  under  the  lobe  of  the  ear,  between  the 
mastoid  process  and  the  ramus  of  the  jaw,  and  extends  upward  in  front 
of  the  ear  and  downward  to  the  neck  (Fig.  104).  The  swelling,  when 
moderate,  can  best  be  appreciated  by  looking  at  the  patient  from  behind 


Fig.  104 

^P^^^^H 

i^^k^ 

i^    »l^  t^l 

^^^B 

^        ■ 

^^K    -^iwHI 

^-    -  ■  a^ 

^K^^^'PvjJ 

Mumps. 

in  a  good  light.  On  palpation  the  swollen  area  is  felt  to  be  smooth, 
slightly  resistant,  and  more  or  less  sensitive  to  pressure.  Both  glands 
may  be  involved  simultaneously,  but  in  the  majority  of  cases  one  precedes 
the  other  by  two  or  three  days  or  there  may  be  a  delay  of  a  week  or  more. 

There  is  pain  on  opening  the  jaw  widely,  and  moderate  soreness  of 
the  throat  on  swallowing.  The  patients  are  apt  to  speak  and  take  food 
through  a  partly  opened  mouth;  the  flow  of  saliva  is  regularly  dimin- 
ished; it  may  be  normal  or  even  increased. 

On  examination  of  the  throat,  at  the  beginning  of  the  disease,  there 
is  often  seen  a  redness  of  the  fauces,  soft  palate,  tonsils,  and  of  the  inner 
surface  of  the  cheek,  together  with  a  swelling  of  the  mucous  membrane 
at  the  orifice  of  Steno's  duct, 
31 


482 


J.\  FKCTKH  -S    !)ISi:.  I SES 


Instead  of  tlie  swrllini:;  lHMn<i;  {'oiifiiiod  to  the  immediate  vicinity  of 
tlie  parotid,  it  may  extend  npward  to  the  orbital  region  and  downward 
over  the  face  and  neek.  WhtMi  this  swelhn*!;  is  hihiteral  the  patients 
present  a  s(|nirrel-hke  ap])earanee.  In  severe  eases  the  skin  over  the 
ati'eeted  parotitl  may  be  reddened  to  a  moderate  extent,  in  which  case 
the  tenderness  on  pressure  is  quite  marked. 

Tlie  disease  may  not  be  confined  to  the  parotid,  but  involve  the 
submaxillary  and  sul)linn;ual  f^lands,  or  one  or  both  of  the  latter  may 
be  swollen  without  the  parotid  or  may  precede  the  swelling  of  the 
latter. 

The  swelling  having  reached  its  height  gradually  subsides,  and  the 
a|)pearance  of  the  gland  is  normal  usually  after  a  week  to  ten  days. 
Relapses  may  occur. 

Even  when  the  disease  begins  with  severe  symptoms,  after  the  first 
twenty-four  hours  the  children  are  not  particularly  ill,  complain  only 
of  a  sense  of  discomfort  and  the  difficulty  in  swallowing,  especially,  solid 
food. 

Complications. — INlumps  is  a  disease  which  in  childhood,  almost 
without  exception,  runs  a  benign  course.  The  complications  so  fre- 
(|uently  observed  in  adults  are  practically  never  seen,  and  the  few 
complicated  cases  described  have  nearly  all  occurred  at  or  near  the  age 
of  puberty.  Orchitis  is  occasionally  seen.  At  its  onset  there  is  often 
high  fever,  restlessness,  and  even  a  mild  delirium,  together  with  pain 
referred  to  the  testicle  and  cord,  with  some  tenderness  on  pressure,  or 
the  symptoms  may  be  so  slight  that  only  an  examination  of  the  testicle 
may  reveal  the  fact  of  its  involvement.  The  duration  of  this  complica- 
tion is  usually  from  three  or  four  days  to  a  week  or  more,  when  complete 
resolution  takes  place.  Atrophy  is  almost  unknown.  Orchitis  may 
occur  at  the  height  of  the  parotid  swelling,  but  usually  during  convales- 
cence. Swelling  of  the  mammary  gland,  not  confined  to  girls,  is  occa- 
sionally seen,  even  at  an  early  age.  Swelling  of  the  ovaries,  with  pain 
and  tenderness  on  deep  pressure,  and  of  the  external  genitals  in  girls 
is  sometimes  met  with. 

Less  common  complications  are:  secondary  involvement  of  the  lymph 
nodes;  suppuration  or  gangrene  of  the  affected  salivary  gland,  due 
to  secondary  infection;  involvement  of  the  thyroid  and  lacrymal  glands; 
paralyses  of  the  various  nerves,  especially  of  the  auditory  nerve,  which 
may  be  followed  l)y  total  and  permanent  deafness;  paralysis  of  the 
facial  nerve,  apparently  due  to  pressure,  and  nephritis. 

Prognosis. — ^Iumps  in  children  is  a  .self-limited  and  rarely  compli- 
cated disease,  running  a  benign  course.     It  is  never  fatal. 

Treatment. — Cases  occurring  in  schools  should  be  isolated.  Strict 
isolation  within  the  house  is  not  necessary.  With  the  onset  of  the  disease, 
the  child  should  be  put  to  bed  and  confined  to  the  house  during  the 
entire  illness.  Sedatives  may  be  refpurcd  at  the  beginning,  and  cold 
sponges  to  reduce  the  fever.  The  diet  should  be  fluid,  preferably  milk. 
To  relieve  the  pain  and  discomfort,  hot  applications,  camphorated  oil, 
or  belladonna  ointment  may  be  applied  to  the  swollen  gland. 


GLANDULAR  FEVER  4g3 

jNIild  solutions  of  boric  acid,  listerine,  or  other  mild  antiseptic  mouth- 
wash should  be  used  several  times  a  day.  When  orchitis  occurs,  rest 
in  bed  is  immediately  indicated,  with  the  application  of  cold  to  the 
affected  part.  Guaiacol  ointment,  25  per  cent.,  as  an  inunction  has  been 
found  efficacious  in  the  treatment  of  this  complication.  Fumigation 
is  not  necessary  except  in  schools  and  other  places  where  a  number  of 
cases  have  occurred.  Under  such  circumstances  a  thorough  cleaning 
and  application  of  antiseptics  may  be  necessary  to  prevent  further 
outbreaks  of  the  disease.  Three  weeks  from  the  beginning  of  the  attack 
may  be  taken  as  the  probable  limit  of  the  infectious  period. 


GLANDULAR  FEVER. 

By  FLOYD  M.  CRANDALL,  M.D. 

In  1889  E.  Pfeiffer  described  a  condition  which  he  called  Glandular 
Fever.  He  described  two  forms  of  the  disease,  the  one  very  rapid  in  its 
course,  the  other  less  rapid,  but  still  an  acute  disorder.  Since  that  time 
numerous  cases  denominated  glandular  fever  have  been  reported,  but 
there  is  grave  doubt  as  to  the  actual  character  of  many  of  them.  Some 
have  unquestionably  been  only  influenza  or  coryza,  with  enlargement 
of  the  lymph  nodes.  Others  have  been  septic  cases,  and  still  others  have 
been  atypical  cases  of  typhoid  fever  or  other  infectious  diseases.  The 
mere  presence  of  the  enlargement  of  lymph  nodes  with  febrile  symptoms 
does  not  warrant  the  diagnosis  of  glandular  fever.  It  is  my  own  belief 
that  there  is  such  a  disease  as  glandular  fever,  but  that  it  is  very  uncom- 
mon and  rarely  occurs  sporadically.  Pfeiffer  asserts  that  it  occurs 
usually  in  epidemics,  but  they  are  of  limited  nature.  All  the  children 
suffer  from  it  when  it  is  introduced  into  a  family.  The  best  work  in  this 
country  on  this  disease  has  been  done  by  West,  Hamill,  and  Seibert, 
and  in  England  by  Dawson  Williams. 

The  most  extensive  and  complete  observations  on  glandular  fever 
are  those  of  J.  Park  West,  of  Bellaire,  Ohio,  reported  in  Archives  of 
Pediatrics,  December,  1896.  He  reports  96  cases  observed  by  himself 
and  Dr.  Korell,  occurring  in  Eastern  Ohio  among  children  between 
the  ages  of  seven  months  and  thirteen  years,  in  forty-three  families. 
Only  twenty  children  of  these  ages  escaped,  but  there  were  numerous 
children,  both  younger  and  older,  who  did  not  contract  it. 

Symptomatology. — The  disease  described  presented  the  following  train 
of  symptoms:  A  sudden  definite  onset  after  a  period  of  incubation;  a 
fever,  running  its  course  in  from  four  to  seven  days  and  terminating  by 
crisis;  characteristic  enlargement  of  the  cervical  lymph  nodes,  forming  an 
elongated  tumor,  lying  below  the  angle  of  the  jaw  anterior  to  the  sterno- 
mastoid  muscle,  beginning  always  on  one  side  and  appearing  later  on 
the  other;  enlargement  in  most  cases  of  other  lymph  nodes,  notably  the 
postcervical,  axillary,  and  inguinal,  and  not  infrequently  the  mesenteric 
and  bronchial;  enlargement  of  the  liver  and  spleen  in  a  large  proportion 


484  INFECTIOUS  DISEASES 

of  rases;  prostration  and  rapidly  dovelopino-  anemia.  The  disease  as 
reeorded  1)V  West  was  elearly  eonlanious,  antl  oeeurrrd  chiefly  between 
the  ages  of  one  and  ten  years.  Dehility  and  a  weak,  rapid  pulse  were 
always  present,  and  were  noticeable  in  most  cases  after  all  other  traces 
of  the  (lisease,  except  some  swelling,  had  disappeared.  The  skin  had 
a  dull,  flushed  appearance,  but  there  was  no  eruption  of  any  kind.  The 
eves  were  heavy  and  fre<|uently  the  pupils  were  widely  dilated. 
"  The  most  marked  feature  in  all  the  cases  reported  l)y  West  was  the 
enlargement  of  the  cervical  or,  to  be  more  definite,  the  carotid  lymph 
nodes.  After  two  to  three  days  of  malaise  the  swelling  could  be  seen. 
As  a  rule  it  i)egan  on  the  left  side  and  reached  full  development  on  the 
second  to  fourth  day.  Several  hours  before  its  completion  on  this  side 
it  would  be  noticed  on  the  right,  and  the  same  course  would  be  followetl 
as  on  the  left.  Occasionally  the  swelling  began  on  the  right  side,  but  in  no 
case  did  it  appear  simultaneously  on  both  sides.  Very  rarely  was  it  con- 
fined to  but  one  side.  The  swelling  always  had  the  same  peculiar  charac- 
teristic appearance.  To  the  eye  it  was  smooth,  but  the  finger  easily 
detected  three  or  four  enlarged  lymph  nodes.  This  swelling  was  elon- 
gated, about  as  thick  as  the  index  finger,  and  ran  downward  and 
forward  from  just  below  the  angle  of  the  jaw,  between  the  body  of  this 
bone  and  the  sternomastoid  muscle,  to  a  little  beyond  the  middle  of 
the  jaw. 

Other  lymph  nodes  in  the  immediate  vicinity  were  swollen,  but  not 
so  much.  The  swelling  was  always  tender,  often  painful,  and  frecpiently 
caused  stiffness  of  the  neck,  and  a  choking  sensation.  In  three-fourths 
of  the  cases  there  was  noticed  enlargement  of  the  other  lymph  nodes 
— postcervical,  axillary,  and  inguinal.  They  were  never  all  enlarged 
in  any  single  case,  nor  were  they  so  much  enlarged  nor  so  tender  as 
the  cervical  nodes.  In  thirty-seven  cases  the  mesenteric  lymph  nodes 
could  be  felt  enlarged.  This  is  probably  considerably  understated,  as 
examination  was  not  made  in  the  earlier  cases. 

The  history  of  the  cases  in  this  epidemic  resembles  very  closely  that 
given  by  Pfeiffer  in  his  second  class,  and  bears  out  his  statement  that 
the  disease  is  of  epidemic  character  that  does  not  extend  beyond  the 
children  of  a  single  house  or  family.  So  far  as  is  known  only  one  adult 
case  has  been  described.  The  disease  is  usually  at  its  height  on  the  third 
or  fourth  day,  at  which  time  the  temperature  reaches  its  uiaximum 
point.  The  acute  symptoms  subside  rapidly,  but  convalescence  is  apt 
to  be  slow  and  tedious.  The  disease  is  rarely,  if  ever,  fatal.  The  most 
serious  and  fre(|uent  complication  is  acute  nephritis,  ten  cases  of 
which  have  been  recorded  in  literature. 

Diagnosis. — There  are  some  who  doubt  the  existence  of  glandular 
fever.  Ashby  and  Wright  are  "rather  inclined  to  think  that  while 
'gland  fever'  does  uniloubtedly  occvu',  it  is  rarely  idioj^athic,  but  the 
results  of  abs()rj)tion  of  toxic  materials  from  a  mucous  luembrane." 
Several  writers  mention  it  as  a  result  of  autointoxication,  with  the  intes- 
tinal tract  as  the  probable  source  of  the  infectious  material.  Others 
are  of  the  opinic^n  that   there  is  a  probable   microbic  influence,  while 


GLANDULAR   FEVER  485 

Comby  states  that  it  may  be  a  streptococcic  infection  with  the  entrance 
through  the  tonsils  without  any  local  lesion.  The  enlargement  of  the 
liver,  spleen,  and  mesenteric  lymph  nodes  certainly  seems  to  indicate 
more  than  a  local  infection.  The  picture  so  clearly  drawn  by  West's 
cases  seems  certainly  to  be  one  of  an  infectious  disease,  but  one  which  is 
not  common  in  the  experience  of  most  physicians.  The  only  disease  of 
which  it  might  be  an  irregular  form  is  mumps,  without  involvement  of  the 
salivary  glands.  But  over  half  of  the  patients  had  already  had  mumps 
or  have  had  them  since.  It  is  important  that  diphtheritic  and  other 
infections  of  the  mucous  membrane  which  cause  enlargement  of  the 
lymph  nodes  should  not  be  mistaken  for  a  glandular  fever. 

Treatment. — The  course  of  glandular  fever  cannot  be  shortened  by 
treatment  nor  can  the  symptoms  be  materially  relieved.  The  stubborn 
constipation  can  be  overcome  by  cathartics,  but  West  found  that  when 
active  cathartics  were  used  the  convalescence  seemed  to  be  more  tedious, 
though  he  found  small  doses  of  calomel  occasionally  useful.  The  pain 
in  the  nodes  in  some  cases  may  be  relieved  by  cold  compresses  and  ice- 
bags,  or  by  hot  camphorated  oil.  During  the  acute  stage  the  child 
should  be  kept  in  bed  and  should  receive  the  diet  and  treatment  adapted 
to  all  febrile  cases.  During  convalescence  tonics  should  be  used,  particu- 
larly iron,  in  the  form  of  the  tincture  of  the  chloride  and  the  syrup  of 
the  iodide,  and  efforts  should  be  made  to  build  up  the  strength  of  the 
child  and  hasten  the  return  to  the  normal  condition,  as  convalescence  is 
especially  slow. 


CHAPTER  XIX. 

SCARLET  FEVER. 
By  FLOYD  M.  CRANDALL,  M.D. 

Scarlet  fever,  or  Scarhitina,  is  an  acute,  infectious,  and  contagious 
disease,  occurring  commonly  during  childhood.  Typical  ca.ses  jM-e.sent 
the  following  features:  After  an  incubation  of  from  three  to  four  days 
there  is  a  sudden  onset  of  sore  throat,  vomiting,  and  fever,  followed 
within  twenty-four  hours  Ly  a  rash,  consisting  of  minute  points  of  a 
scarlet  color  closely  grouped  on  a  reddened  skin,  which  appears  first  on 
the  neck  and  extends  rapidly  over  the  body.  The  eruption  continues 
from  four  to  six  days  and  is  followed  by  a  stage  of  tlesquamation  which 
continues  from  three  to  six  weeks.  The  disease  may  be  contagious 
from  the  first  svmptoms,  but  is  usually  not  contagious  until  the  rash 
has  appeared.  The  period  of  contagion  continues  until  desquamation 
is  complete. 

Etiology.  Exciting  Caiuses. — Scarlet  fever  is  beyond  all  doubt  an 
infectious  disease,  but  the  specific  germ  has  not  yet  been  discovered.  It 
seems  certain  that  sfrrpfororci  play  an  important  role  in  the  causation 
of  .some  of  the  symptoms,  but  the  evidence  seems  to  be  growing  stronger 
that  streptococci  are  not  the  cause  of  the  disease  itself.  The  recent 
studies  of  Hektoen,  Weaver,  and  Ruedinger  strengthen  the  idea  that 
the  streptococcus  is  an  important  factor  in  making  up  the  symptom- 
complex  of  scarlet  fever,  but  lend  no  support  to  the  claim  that  it  is  the 
specific  organism.  Hektoen  points  out  that  while  streptococci  may  be 
found  in  the  blood  and  internal  organs  after  death,  they  are  sought  for 
in  vain  in  the  early  .stages  and  are  absent  in  the  majority  of  cases  until 
late  in  the  disease.  The  significance  of  the  fact  that  streptococci  are 
largelv  fomid  after  death  is  lessened  by  the  other  fact  that  in  many  con- 
ditions like  measles,  diphtheria,  and  smallpox  the  same  organisms  are 
frequently  found.  The  most  reasonable  assumption  at  present  is  that 
in  .scarlet  fever  we  have  usually  a  mixed  infection  by  the  streptococcus 
and  a  yet  unknown  specific  germ. 

Weaver  asserts  that  streptococci  obtainccl  from  the  throat  of  scarlatinal 
patients  are  not  different  in  structural,  cultural,  and  morphological  pecu- 
liarities from  the  streptococci  obtained  from  other  sources.  Baginsky 
found  scarlatinal  blood  serum  to  have  no  agglutinating  action  upon 
streptococci,  l)ut  Moser  has  produced  a  serum  which  agglutinates  strep- 
tococci from  scarlatinal  cases  in  a  different  maimer  from  other  strepto- 
cocci. Weaver  and  Ruedinger  also  failed  to  find  any  agglutiiuiting 
C486) 


SCARLET  FEVER  487 

action.  These  observations  seem  to  strengthen  the  idea  that  the 
streptococcus  obtained  so  often  from  the  bodies  of  those  who  have  died 
from  scarlet  fever  is  nothing  but  the  common  streptococcus  and  not 
the  specific  micro-organism  of  scarlet  fever. 

Some  recent  observations  have  been  made  which  show  that  the  severity 
of  the  disease  is  in  direct  proportion  to  the  streptococcemia.  Among 
the  cases  designated  as  mild,  streptococci  were  found  during  the  first 
week  in  but  9  per  cent.,  while  in  those  designated  severe  they  were  found 
in  27  per  cent.  Whatever  the  cause  of  the  primary  disease  may  be  proved 
in  the  future  to  be,  it  is  certain  that  streptococci  are  the  cause  of  some 
of  the  secondary  symptoms,  and  must  be  regarded  as  important  factors 
in  the  production  of  the  usual  clinical  picture  which  we  know  as 
scarlet  fever.  Staphylococci  and  diphtheria  bacilli  are  sometimes  found 
in  conjunction  with  the  streptococci.  These  germs  were  present  in  a 
recent  case  of  my  own. 

It  seems  certain  that  the  specific  germ  of  scarlet  fever  exists  in  the 
blood,  for  inoculation  of  the  serum  into  susceptible  animals  produces  a 
typical  attack  of  the  disease.  It  must  also  exist  in  the  secretions  of  the 
mucous  membranes,  in  the  desquamation  scales,  and  possibly  in  the 
excretions,  as  shown  by  their  power  to  generate  the  disease.  Some  of 
these  questions  cannot  be  settled  definitely  until  the  specific  micro- 
organism is  found. 

Predisposing  Causes. — iVmong  the  predisposing  causes  age  must 
be  placed  first.  The  disease  is  rare  under  one  year,  but  I  have  seen  an 
undoubted  attack  of  scarlet  fever  in  an  infant  of  one  week.  It  should 
not  be  forgotten  that  albumin  is  sometimes  found  in  the  urine  during 
the  first  days  of  life,  its  presence  then  being  of  little  significance.  After 
the  first  week  its  occurrence  is  of  the  same  significance  as  later  in  life. 
It  is  also  to  be  remembered  that  hyaline  casts  may  frequently  be  found 
in  the  urine  of  perfectly  healthy  infants  during  the  first  week  of  life. 
Granular  casts  are  also  found,  but  are  less  common  than  the  hyaline. 
It  is  thus  evident  that  during  the  first  week  or  ten  days  of  life  urinary 
analysis  may  prove  very  misleading  if  judged  by  the  adult  standard, 
and  the  presence  of  albumin  and  casts  may  not  indicate  an  infectious 
disease.  Up  to  five  years  the  susceptibility  to  the  disease  steadily 
increases  and  reaches  its  maximum;  after  eight  years  it  rapidly  decreases, 
and  is  slight  during  adult  life.    Sex  does  not  influence  its  occurrence. 

Scarlet  fever  is  a  far  less  common  disease  than  is  measles  and  suscep- 
tibility to  it  seems  to  be  much  less.  While  almost  every  child  who  has 
not  already  had  measles  may  be  expected  to  contract  it  upon  exposure, 
at  least  half  the  children  exposed  to  scarlet  fever  may  be  expected  to 
escape  unless  the  exposure  is  close  and  prolonged.  Epidemics  of  scarlet 
fever  are  usually  less  frequent  than  those  of  measles  and  are  rarely  as 
widespread.  Epidemics  are  most  common  during  the  fall  and  winter 
months.  Several  observers  have  found  it  to  be  more  common  during 
October  than  in  any  other  month  of  the  year,  and  the  mortality  higher. 
Epidemics  of  scarlet  fever  usually  spread  very  slowly  as  compared  with 
those  of  measles. 


488  INFECTIOUS  DISEASES 

Sources  of  Infection. — The  chief  source  of  infection  is  the  patient 
himself,  but  the  area  of  coiitajjjion  is  Hmited  to  a  few  feet.  The  desqua- 
mation scales  ai'e  extremely  infectious.  Their  retention  by  clothing, 
bedding,  and  the  walls  of  the  rooms  is  one  of  the  most  common  causes 
of  infection.  The  purulent  secretions  from  the  throat,  nose,  and  ear 
are  also  very  infectious.  Scarlet  fever  is  spread  by  indirect  infection 
more  frequently  than  any  other  disease  except  smallpox.  Its  specific 
micro-organism  is  more  t(  nacit)us  of  life  than  that  of  any  other  dis- 
ease except  perhaps  smallpox.  It  may  be  conveyed  from  one  child 
to  another  in  the  fur  of  cats  and  dogs,  and  it  is  probable  that  these 
animals  may  suffer  from  the  disease.  The  contagion  clings  to  rooms 
with  great  tenacity,  being  frecjuently  lodged  in  the  wall-paper  or  in 
cracks  of  the  walls,  ceilings,  and  floors.  The  conveyance  of  scarlet 
fever  by  milk  and  other  articles  of  food  is  undoubted.  The  celebrated 
epidemics  of  Hendon  and  Wimbledon  were  believed  by  Dr.  Klein  to 
be  due  to  scarlet  fever  in  the  cows,  but  this  belief  has  not  been  sub- 
stantiated. It  is  probable  that  the  disease  from  which  those  cows 
suffered  was  not  true  scarlet  fever. 

The  disease  has  been  conveyed  by  letters  written  by  hands  in  the 
stage  of  desquamation.  An  attendant  upon  a  case  of  scarlet  fever  may 
easily  carry  the  infection  to  other  children  by  the  clothes,  hands,  or 
beard.  Such  transmission  is  probably  not  common,  however,  except 
when  the  contact  has  been  close  and  somewhat  prolonged.  The  clothing 
of  a  nurse  which  comes  in  close  contact  with  a  patient  for  extended 
periods  of  time  may  be  highly  infectious.  It  is  certain  that  the  greatest 
danger  of  infection  lies  in  the  transmission  of  the  desquamation  scales. 
Holt  asserts  that  in  a  city  the  bed-clothing  while  airing  in  a  window 
has  been  known  to  convey  the  disease  to  an  adjoining  house,  and  records 
also  the  same  result  from  the  washing  of  infected  with  other  clothes. 
It  would  scarcely  seem  possible  that  scarlet  fever  could  be  conveyed 
through  two  healthy  persons,  but  a  few  apparently  authentic  cases  of 
this  kind  have  been  recorded.  This  would  apparently  result  from  the 
transmission  from  person  to  person  of  desquamation  scales. 

Portal  of  Entrance. — The  portal  of  entrance  is  undoubtedly  in  most 
cases  the  nasopharynx.  It  is  here  that  the  first  local  symptoms  appear, 
and  the  secondary  micro-organisms  at  least  commonly  enter  the  system 
at  this  point. 

Period  of  Incubation. — The  period  of  incubation  is  shorter  than  that 
of  any  other  infectious  disease  except  perhaps  influenza  and  diphtheria. 
The  extremes  range  from  a  few  hours  to  fifteen  days.  In  87  per  cent, 
of  cases  Holt  found  the  period  to  be  less  than  six  days,  and  in  66  per 
cent,  between  two  and  three  days.  In  my  own  experience  the  incubation 
period  has  been  short.  In  one  case  a  child  who  had  not  been  exposed 
either  directly  or  indirectly  came  in  contact  with  the  disease  in  the  late 
afternoon  and  developed  the  initial  symptoms  the  following  morning. 
Many  of  the  cases  of  prolonged  incubation  present  elements  of  un- 
certainty. The  cases  in  which  the  incubation  is  longer  than  one  week 
are  extremely  rare. 


SCARLET   FEVER 


489 


Period  of  Contagiousness. — While  the  period  of  incubation  is  short, 
the  period  of  contagion  is  longer  than  in  that  of  any  other  disease  except 
possil)ly  smallpox.  The  disease  is  not  contagious"  during  the  period  of 
incubation,  but  it  may  be  so  from  the  first  appearance  of  changes  in 
the  throat.  It  is  rare,  however,  that  it  becomes  contagious  until  the 
rash  develops.  A  child  may  escape  the  disease  who  has  slept  in  the 
same  bed  with  another  on  the  night  that  the  rash  develops.  I  have 
recently  seen  two  marked  instances  of  this  kind.  The  most  actively 
contagious  period  is  at  the  height  of  the  febrile  stage  on  the  third,  fourth, 
and  fifth  days.  The  infectious  power  then  diminishes,  but  increases 
again  during  the  stage  of  desquamation.  The  period  of  contagion 
continues  until  the  last  vestiges  of  desquamation  have  disappeared, 
and  usually  covers  the  conventional  forty  days. 

The  desquamation  scales  are  not  the  only  source  of  infection  during 
the  later  stages.  The  possibility  that  purulent  discharges  from  the 
mucous  membranes  and  cavities  of  the  body  might  be  infectious  was 
for  many  years  strangely  overlooked.  A  purulent  rhinitis  or  otitis, 
suppurating  lymph  nodes,  or  even  a  pharyngitis  or  eczema  may  transrfit 
the  disease  for  weeks  after  desquamation  has  ceased.  Chronic  nasal 
or  pharyngeal  catarrh  may  keep  the  scarlatinal  germs  alive  for  long 
periods  of  time.  Holt  refers  to  the  opening  of  a  postscarlatinal  empyema 
in  a  surgical  ward  which  was  followed  by  an  outbreak  of  scarlet  fever. 
It  is  this  persistence  of  the  specific  germ  in  purulent  discharges  which 
accounts  largely  for  the  "return"  cases.  Ashby  asserts  that  from  2  to 
4  per  cent,  of  the  cases  discharged  from  a  certain  scarlet  fever  hospital 
subsequently  conveyed  the  disease.  J.  Wright  Mason  assigns  the 
following  three  causes  for  return  cases:  (1)  Imperfect  disinfection  of 
the  clothing  of  the  first  patient;  (2)  the  retention  of  poison  in  the  skin 
or  throat,  or  most  often  in  the  discharges  from  the  throat,  nose,  or  ears; 
(3)  infection  contracted  before  leaving  the  hospital  by  patients  admitted 
for  other  diseases. 

Millard,  in  a  study  of  4910  cases  of  scarlet  fever  which  had  been 
isolated  for  a  period  of  8.3  weeks  from  the  initial  symptoms,  found  that 
158  carried  infection  upon  their  return  home  and  caused  171  new  cases. 
He  believes  that  the  chief  sources  of  this  late  infection  were  purulent 
discharges  from  the  nose  and  ear.  These  facts  teach  the  lesson  that 
time  alone  and  even  the  disappearance  of  the  desquamation  do  not 
furnish  a  safe  guide  for  the  remitting  of  c|uarantine.  It  is  impossible 
to  say  for  how  long  a  period  the  infective  principle  of  scarlet  fever 
contained  in  the  desquamation  scales  may  retain  its  vitality  when 
packed  away  in  clothing,  carpets,  or  upholstery.  Authentic  cases  are 
recorded  in  which  the  period  was  a  year  or  more.  Clothing  packed 
away  in  trunks  or  chests  is  especially  dangerous,  for  the  infection  remains 
in  them  much  longer  than  in  articles  exposed  to  the  light  and  air. 

Pathology. — Scarlet  fever  presents  no  characteristic  or  distinctive 
lesions.  Such  lesions  as  there  are  are  confined  to  the  skin  and  throat. 
The  lesions  of  the  skin  are  those  of  acute  dermatitis.  The  papillse  and 
the  stratum  beneath  become  infiltrated  with  fluid,  while  about  the 


490  INFECTIOUS  DISEASES 

bloodvessels  are  collections  of  leukocytes.  The  production  of  epithelium 
is  greatly  increased  during  the  acute  stages,  which  results  later  in  profuse 
exfoliation  of  the  superficial  layers.  In  the  later  .stages,  in  addition  to 
this,  according  to  Neumann,  there  is  also  a  profuse  development  of 
exudative  cells,  particularly  among  the  ducts  and  follicles.  These  cells 
Ciisily  reach  the  epitiielial  surface,  a  fact  which  accounts  for  the  great 
infectiousness  of  the  descjuaniatiug  cells.  The  throat  changes  in  uncom- 
plicated scarlet  fever  are  catarrhal  in  nature,  and  are  an  es.sential  part 
of  the  disease.  The  croupous  and  diphtheritic  membranes  must  be 
considered  as  complications.  The  changes  in  the  kidneys  are  those  of  a 
diffuse  nephritis. 

Clinical  Types. — Scarlet  fever  is  the  most  irregular  of  all  the  eruptive 
fevers  in  its  severity  and  manifestations  in  different  individuals.  From 
the  attack  so  mild  that  diagnosis  is  difficult  to  the  fiercely  malignant  form 
we  see  every  possible  degree  of  severity.  The  majority  of  cases,  however, 
pursue  a  fairly  uniform  course  and  may,  with  propriety,  be  called  ordi- 
nary cases.  Other  types  may  be  described  as  mild,  severe,  and  malignant. 

Ordinary  Type.— In  the  ordinary  or  common  type  the  onset  is 
sudden  and  is  characterized  by  vomiting,  fever,  sore  throat,  and 
rapid  pulse.  Occasionally  a  short  period  of  malaise  precedes  the 
onset  of  definite  .symptoms.  In  older  children  a  chill  is  some- 
times the  first  symptom;  in  younger  children  a  convulsion.  The 
vomiting  is  usually  repeated  several  times  and  may  not  be  accom- 
panied by  nausea.  ^Mien  it  occurs  late  in  the  disease  it  is  a  far  more 
unfavorable  symptom  than  at  the  outset.  The  intensity  of  the  period 
of  invasion  is  usually  indicative  of  the  severity  of  the  attack,  though 
this  is  a  rule  subject  to  many  exceptions.  The  tongue  is  at  first  coated 
white.  After  three  or  four  days  it  rapidly  clears  and  becomes  clean  and 
red,  with  prominent  papilla?,  the  true  strawberry  tongue. 

Within  twenty-four  hours  after  the  invasion  and  usually  within  twelve 
hours  the  characteristic  eruption  begins  to  appear.  There  is  frequently 
intense  itching  or  burning  of  the  skin.  The  rash  is  usually  well  devel- 
oped during  the  second  day  of  its  appearance.  It  then  continues  from 
four  to  six  days,  when  it  gradually  subsides.  It  usually  appears  first 
over  the  front  of  the  neck  and  upper  part  of  the  chest. '  It  consists  of 
minute  points  of  bright-scarlet  color  closely  grouped  together  on  a 
reddened  skin.  The  points  become  confluent  in  places,  forming  bright- 
colored  patches,  but  over  the  most  of  the  surface  they  remain  discrete 
throughout.  Being  hyperemic  in  nature,  the  rash  disappears  on  pressure, 
leaving  for  a  perceptible  time  a  white  spot. 

l)es(|uaniation  is  perhaps  the  most  characteristic  symptom  of  all  forms 
of  scarlet  fever.  In  no  other  disease  does  such  extensive  desquamation 
occur.  Ahhough  in  mild  cases  it  is  sometimes  comparatively  slight,  it  is 
always  present  if  sought  for.  It  rarely  begins  before  the  sixth  day,  and  is 
frecjuently  delayed  until  the  second  week.  It  appears  first  on  the  neck 
and  body  or  between  the  fingers.  It  begins  as  fine,  branny  .scales,  but 
soon  changes  to  large  lamellar  scales.  Sometimes  the  skin  can  be 
peeled  off  in  strips.     It  continues  from  t(>n  to  thirty  days,  and  is  most 


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SCARLET  FEVER  49 1 

persistent  where  the  skin  is  thickest.  It  usually  continues  on  the  fingers 
and  around  the  nails  after  other  portions  of  the  body  are  clear,  which 
explains  the  readiness  with  which  the  disease  is  conveyed  by  letters. 

Mild  Type. — One  of  the  most  peculiar  features  of  scarlet  fever  is  its 
ability  sometimes  to  appear  in  extremely  mild  form.  The  symptoms 
are  sometimes  so  slight  that  medical  aid  is  not  sought,  and  in  other 
cases  diagnosis  is  difficult  before  the  stage  of  desquamation.  As  a  rule, 
however,  there  is  an  onset  of  vomiting,  fever,  and  sore  throat  as  in  the 
ordinary  type,  but  none  of  the  symptoms  is  so  urgent.  The  vomiting 
is  not  persistent,  the  temperature  does  not  rise  above  102°  or  103°  F., 
and  the  throat  presents  only  the  symptoms  of  mild  pharyngitis.  I  have 
seen  an  undoubted  case  in  which  the  temperature  never  rose  to  101°  F. 
The  temperature  may  become  normal  on  the  fourth  day.  The  eruption 
is  often  faint  and  may  not  appear  on  the  face.  It  may,  however,  be 
bright  and  distinctive  for  twenty-four  hours  and  then  fade  away  so 
rapidly  as  to  have  disappeared  by  the  fifth  day.  In  rare  instances  it 
is  an  evanescent  rash,  which  disappears  entirely  within  twenty-four 
hours.  Nephritis  may  be  a  sequel,  due  in  many  cases  to  exposure  and 
lack  of  care,  the  natural  results  of  so  mild  an  illness.  Owing  to  this 
lack  of  care  and  isolation,  the  patient  may  become  very  dangerous  to 
others.  It  is  by  these  mild  cases  that  the  disease  is  sometimes  sown 
broadcast.  A  mild  attack  in  one  child  may  produce  a  malignant  one 
in  another.  The  "scarlatina"  of  the  laity  is  often  the  cause  of  the 
disease  in  schools  and  institutions  (Figs.  105  and  106). 

Severe  Type. — This  type  differs  from  the  usual  form  not  only  from 
the  fact  that  the  symptoms  are  aggravated,  but  the  various  stages  are 
usually  prolonged.  The  fever  may  continue  for  three  weeks  or  more 
and  the  stage  of  desquamation  for  even  a  longer  time.  A  fatal  termi- 
nation is  common,  death  occurring  usually  during  the  second  week. 
The  chief  peculiarity  which  distinguishes  this  from  the  ordinary  form 
is  the  presence  of  septic  symptoms  due  to  streptococcic  infection.  The 
type  might,  therefore,  with  propriety  be  called  the  complicated  type. 
The  throat  is  usually  first  to  show  the  evidence  of  streptococcic  invasion. 
On  the  third  day,  and  in  some  cases  on  the  first  or  second  day,  a  mem- 
branous exudate  appears  on  the  tonsils  and  soon  invades  the  pharynx 
and  nasopharynx.  A  purulent  nasal  discharge  appears  and  the  lymph 
nodes  at  the  angle  of  the  jaw  begin  to  swell,  the  cellular  tissues  being 
so  involved  as  to  often  cause  immense  enlargement.  The  Eustachian 
tubes  are  involved  and  purulent  otitis  media  follows,  but  the  larynx 
commonly  escapes.  The  urine  contains  albumin,  perhaps  blood  cells 
and  hyaline  and  epithelial  casts.  Symptoms  of  general  septic  infection 
rapidly  supervene.  There  is  low  dehrium  or  stupor;  the  child  refuses 
nourishment  and  may  die  from  exhaustion,  but  sudden  death  is  not 
uncommon.  Others,  after  overcoming  one  symptom  after  another,  slowly 
recover  after  a  tedious  convalescence. 

This  type  often  differs  so  radically  in  its  symptoms  from  the  uncom- 
plicated type  as  to  seem  like  another  disease.  In  the  one  we  have  an 
infectious  disease,  running  a  definite  course  and  presenting  few  urgent 


492  IXFECTIOrs  DISEASES 

symptoms.  In  \\\c  otlicr  we  \\n\v  ;i  tyj>ical  pictiur  of  septic  infection. 
The  counteniuuv  is  <]jray  or  of  the  fjcreenisli-yellow,  septic  hue.  The 
breath  is  fetid  and  there  is  an  offensive  (Hseharire  from  the  mouth  and 
nose,  'i'he  fever  is  high,  the  pulse  rapid  and  weak,  and  there  is  either 
stupor  or  dehrium.  Sordes  collect  upon  the  teeth,  the  mouth  is  sore, 
and  the  head  is  thrown  back  to  relieve  the  dyspnea.  Albumin  appears 
in  the  urine  and  cardiac  or  ])ulni()nary  complications  are  apt  to  super- 
vene. The  appearance  of  the  j)atient  is  usually  (juite  different  from 
that  of  the  one  pjissing  through  an  uncomj)licated  attack. 

The  disease  occasionally  ajipears  in  severe  but  not  strictly  malignant 
form  in  which  there  are  no  comj)lications,  but  the  patient  is  placed  in 
great  danger  or  dies  from  the  severity  of  the  disease  itself.  In  some 
epidemics  such  cases  are  comparatively  common.  In  still  other  cases 
the  local  symptoms  are  severe,  but  the  general  septic  infection  is  mild. 

Malignant  Type. — This  form  of  the  disease  is  fortunately  rare.  It 
was  formerly  without  doubt  more  common  than  it  is  now.  Hence, 
scarlet  fe\er  was  a  more  dreaded  disease  foi'ty  or  fifty  years  ago  than 
it  has  been  during  the  past  twenty  years.  This,  at  least,  seems  to  be 
true  in  the  Eastern  United  States.  The  scarlatinal  poison  may  be  so 
intense  as  to  cause  death  within  twenty-four  hours.  INIore  commonly 
death  does  not  occur  before  the  third  or  fourth  day,  the  patient  being 
comatose  or  delirious.  The  nervous  symptoms  are  so  marked  that  some 
physicians  have  given  this  form  the  name  of  cerebral  scarlet  fever.  In 
a  case  of  my  own  the  initial  symptoms  were  convulsions,  hyperpyrexia, 
and  hematuria.  In  another  case  hyperpyrexia  and  coma  appeared  at 
the  outset,  the  patient  dying  soon  after  the  rash  began  to  appear.  In 
an  epidemic  occurring  in  the  practice  of  my  fatluM-  about  forty  years 
ago,  the  eruption  was  hemorrhagic  in  character  antl  the  patients  died 
within  the  first  two  or  three  days.  The  peculiar  eruption  and  cerebral 
symptoms  led  some  physicians  in  the  early  stages  of  the  epidemic  to 
make  a  diagnosis  of  cerebrospinal  meningitis.  Although  a  temperature 
of  100°  or  107°  F.  is  commonly  seen  in  such  cases,  a  very  low  temper- 
ature sometimes  occurs,  with  great  prostration.  The  scarlatinal  poison- 
ing is  so  intense  in  these  cases  that  the  patient  seems  to  be  overwhelmed 
by  it.  Death  results  from  the  intense  poison  of  the  disease  rather  than 
from  complications. 

Surgical  Scarlet  Fei^er. — Patients  who  have  undergone  surgical  oper- 
ations are  unquestionably  very  susceptible  to  scarlet  fever.  Such  scarlet 
fever,  however,  is  not  essentially  different  from  the  ordinary  disease. 
It  is  simple  scarlet  fever  in  a  surgical  case.  It  is  no  doubt  true,  as 
Osier  has  shown,  that  the  eruption  which  has  frequently  led  to  a  diag- 
nosis of  scarlet  fever  is  nothing  more  than  the  red  rash  of  septicemia. 
It  is  a  fact  that  surgical  scarlet  fever  is  less  common  since  surgical 
septicemia  has  become  less  frequent.  Hoffa  has  attempted  to  make  a 
classification  of  the  rashes  which  are  seen  in  surgical  cases.  These  he 
flivides  into  three  classes  as  follows:  (1)  Those  due  to  vasomotor 
irritation  and  seen  chiefly  after  operations  where  the  nerve  supply  is 
abundant.     The  rash  occurs   within   a   few   hours   and    resembles   an 


SCARLET  FEVER 


493 


erythema  and  usually  disappears  after  a  few  hours.  (2)  "Toxic  erythe- 
mas," which  appear  usually  on  the  second  day  after  operation  without 
prodromal  symptoms.  There  is  frequently  fever  and  gastric  disturbance. 
The  rash  may  be  simply  a  diffuse  redness  or  there  may  be  large,  isolated 
red  patches.  It  frequently  disappears  within  twenty-four  hours  without 
desquamation.  This  condition  is  due  to  the  absorption  of  wound 
secretions  like  fibrin  ferment  and  is  analogous  to  the  eruption  following 
the  administration  of  such  drugs  as  antipyrin  or  copaiba.  (3)  The 
eruptions  of  pyemia  and  septicemia  which  indicate  general  septic  infec- 
tion. They  may  be  diffused  or  in  patches  and  sometimes  closely  simulate 
the  eruption  of  scarlet  fever. 

True  surgical  scarlet  fever  is  usually  atypical  in  its  manifestations. 
The  throat  symptoms  are  not  always  characteristic  and  the  rash  is 
often  irregular  in  its  appearance  and  manifestations.  The  consti- 
tutional symptoms  are  frequently  grave  in  nature.    While  caution  should 


Fig. 105 


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Very  mild  scarlet  fever  in  a  boy  of  five  years,  complicated  by  otitis  with  discharge  from  the  left  ear 
on  the  sixth  day  and  from  the  right  ear  on  the  ninth  day. 


be  exercised  in  allowing  a  case  to  pass  unrecognized,  the  diagnosis  should 
certainly  not  be  made  in  atypical  cases  in  which  no  desquamation 
follows. 

Symptomatology.  I  invasion. — The  invasion  of  scarlet  fever  is  usually 
characteristic,  but  is  subject  to  many  variations.  In  typical  cases  the 
invasion  is  usuallv  more  abrupt  than  in  most  diseases.  The  vomiting, 
sore  throat,  high  temperature,  and  rapid  pulse  are  a  combination  of 
symptoms  which  should  always  put  the  physician  on  his  guard.  Either 
of  these  S}Tnptoms,  however,  may  be  absent.  In  my  last  three  cases 
there  was  no  vomiting  at  any  time  and  in  two  of  them  the  sore  throat  was 
not  marked.  Scarlet  fever  is  often  mistaken,  at  the  first  visit  for  tonsil- 
litis. The  sudden  fever,  malaise,  and  sore  throat,  in  conjunction  with 
tonsils  covered  with  a  punctate  exudation,  make  some  cases  appear  like 
tonsillitis.    In  a  considerable  number  of  cases  the  onset  is  gradual  and 


494 


ISFECTK >rs   DISK. \ SES 


the  early  symptoms  arc  indefinite.     In  general  terms  the  more  severe 
the  attaek  the  more  distinctive  the  onset.     In  rare  eases  a  eiiill  is  the 


Fiii.  ion 


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Uncomplicated  scarlet  fever  of  mild  type  in  a  girl  of  six  years. 
Fig. 107 


105" 

M      EMEU      EMEU      EVE      MEMEM;E 

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""^H   |2|riS!B|5i  =  !lMi|iFl  =  l^l-^l'|Sr,-,^;»-V'-:-i-|'l'l'l~l-''i'l'l 

Uncomplicated  scarlet  fever  of  moderate  severity  in  a  boy  of  twelve  years,  marked  by  a  prodromal 
stage  of  lassitude  and  nausea  lasting  six  hours  before  the  advent  of  vomiting  and  fever ;  follicular 
spots  on  each  tonsil  with  moderate  rash  on  the  second  day  ;  follicular  spots  almost  invisible,  nausea 
ceased,  but  rash  inten.'^  on  the  fourth  day ;  desquamation  on  the  body  on  the  eighth  day,  becoming 
profuse  two  days  later;  des<|uamation  beginning  on  the  fingers  and  toes  on  the  eleventh  day  ;  des- 
quamation complete  on  the  body,  but  still  free  on  the  hands  and  feet  on  the  twenty-fourth  day; 
released  from  isolation  on  the  thirty-sixth  day. 


first  .symptom.     This  is  more  common  in  older  children  and  adults. 
In  yonng  children  a  convulsion  may  he  the  initial  symptom. 

Temperature. — There  is  no  tvpical  temperature  range  in  scarlet  fever, 
as  there  is  in  such  diseases  as  pneumonia  and  typhoid  fever  (Figs.  105 


SCARLET  FEVER 


495 


to  110).  It  is  a  disease,  however,  in  which  the  temperature  usiiaUy 
ranges  high.  The  height  of  the  temperature  at  the  onset  is  to  a  certain 
extent  an  indication  of  the  severity  of  the  attack.  A  temperature  on 
the  first  day  above  104.5°  F.  gives  promise  of  a  severe  attack;  below 
102°  F.,  of  a  mild  attack.  The  temperature  usually  reaches  its  highest 
point  on  the  second  or  third  day  in  uncomplicated  cases.  It  is  frequently 
remittent  and  in  mild  cases  almost  intermittent.  Occasionally  the 
highest  temperature  will  be  found  on  the  first  day.  A  falling  temperature 
after  the  first  or  second  day  is  indicative  of  a  mild  attack.  A  rising 
temperature  after  the  third  or  fourth  day  usually  indicates  a  compli- 


FiG.  108 


106° 

105' 
lOl 

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111 

1  102° 

1  lOf 

100 

99° 

98° 

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Uncomplicated  scarlet  fever  in  a  girl  of  seven  years,  running  a  somewhat  prolonged  course  of  more 
than  usual  severity  ;  onset  sudden  with  rash  distinctly  marked  within  twelve  hours,  reaching  its 
height  on  the  third  day,  continuing  for  four  days  and  disappearing  only  at  the  end  of  the  tenth 
day  ;  desquamation  beginning  on  the  eleventh  day  and  lasting  on  the  hands  and  feet  until  the 
forty-sixth  day  ;  a  grayish-white  exudate  on  the  tonsils  on  the  third  day,  increasing  on  the  following 
day,  and  then  slowly  disappearing ;  moderate  adenitis  from  the  fourth  to  the  eighth  day. 

cation  and  is  always  a  M^arning  signal  which  should  not  be  neglected. 
Normally  the  temperature,  even  in  severe  cases,  begins  to  subside  as 
the  rash  begins  to  fade.  Any  departure  from  this  general  principle  is 
usually  indicative  of  a  complication. 

Pulse.— A  rapid  pulse  is  characteristic  of  scarlet  fever.  I  have  come 
to  look  upon  it  as  an  aid  in  making  a  diagnosis  in  uncertain  cases. 
A  pulse  of  120  with  mild  and  perhaps  not  urgent  symptoms  is  not 
uncommon.  It  is  frequently  found  to  be  140  or  150  at  the  first  visit,  and 
while  by  no  means  pathognomonic,  it  is  certainly  most  suggestive. 

Throat— Sore  throat  is  one  of  the  most  constant  of  the  initial  symp- 
toms of  scarlet  fever.     As  already  stated  it  is  frequently  mistaken  for 


496 


IXFECTIOrS  DISEASES 


tonsilliti.-;  at  the  outlet, 
liable  to  be  iii  patches. 


Fig.  109 


M     E      V     E      '>■      E      V     e!m     e'mE     mIe 

M  ,  E 

lOi 

t             .III 

106 

I 
^105 

a 
3 

51(4 

a. 
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103 

10-i 

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sjl  2jgjS;g|5'£| 

Scarlet  fever  in  a  girl  of  three  years  compli- 
cated on  the  third  day  by  extensive  membranous 
angina  with  extreme  adenitis  and  cellulitis  and 
by  pneumonia  on  the  seventh  day ;  death  on  the 
eighth  day. 


In  such  cas;es  an  exiulate  appears  early  and  is 
In  such  tliroats  there  is  almost  invariably  more 
swelling  and  diffuse  redness  than 
is  seen  in  tonsillitis.  The  conges- 
tion extends  forward  onto  the  hartl 
palate  and  the  uvula  is  swollen 
and  is  sometimes  edematous.  In 
other  words,  the  inflammation  of 
the  throat  is  usually  more  exten- 
sive and  severe  than  it  commonly 
is  in  tonsillitis.  As  a  rule,  the 
exudates  do  not  appear  until  the 
third  or  fourth  day.  They  are 
then  less  like  the  exudates  of  ton- 
silHtis,  being  smeared  over  the  ton- 
sils and  adjoining  tissues  in  irreg- 
ular patches.  The  exudates  which 
appear  during  the  first  week  are 
usually  caused  by  streptococci  or 
staphylococci,  and  are,  therefore, 
pseudodiphtheria.  The  exudates 
which  appear  late  in  the  disease  are 
almost  invariably  truly  diphtheritic  in  nature.  Diphtheria  sometimes 
appears  at  the  outset  also.  A  diagnosis  cannot  always  be  made  with- 
out a  bacterial  culture.  Streptococci,  staphylococci,  and  Klebs-Ix)effler 
bacilli  may  all  be  present.  The  angina  when  severe  is  usually  accom- 
panied by  a  discharge  from  the  nose  of  a  clear,  tenacious  mucus  or 
mucopus.  This  may  go  on  to  cause  complete  obstruction  of  the  nasal 
passages.  Such  a  condition  is  very  prone  to  be  followed  by  otitis.  The 
more  decidedly  purulent  the  nasopharyngeal  inflammation,  the  greater 
the  danger  of  otitis.  The  simple  angina  of  scarlet  fever  as  w^ell  as  the 
nasopharyngeal  symptoms  reach  their  height  coincident  with  the  erup- 
tion and  the  other  symptoms,  and  gradually  subside  as  improvement 
occurs  in  other  directions.  In  many  cases  there  is  no  exudate  in  the 
throat  during  the  whole  course  of  the  disease.  There  is  diffuse  red- 
ness with  fine,  dark  macules,  but  nothing  more.  There  may  even  be 
considerable  swelling  without  the  appearance  of  any  membrane.  In 
some  cases  the  child  complains  of  severe  soreness  when  there  is  nothing 
to  be  seen  except  diffuse  redness. 

Membranous  sore  throat  is  not  a  necessary-  part  of  scarlet  fever.  Many 
cases  pass  through  their  entire  course  without  showing  any  membrane. 
It  must,  therefore,  be  considered  a  complication  and  not  an  essential 
feature  of  the  disease  and  will  V)e  considered  in  a  later  section. 

Adenitis. — In  most  cases  of  scarlet  fever  of  ordinary'  severity  the 
lymph  nodes  at  the  angle  of  the  jaw  are  somewhat  involved.  This  may 
occur  even  in  the  milder  cases.  They  mav  be  felt  as  small  kernels  and 
are  frequently  not  sore.  ^Mien  the  angina  Is  severe,  however,  they 
become  more  seriously  involved  and  may  go  on  to  acute  inflammation 


SCARLET  FEVER 


497 


or  suppuration.  When  this  occurs  there  is  usually  marked  cellulitis 
as  well.  While  slight  involvement  of  the  lymph  nodes  is  the  rule,  the 
more  serious  disorders  are  not  essential  to  the  disease  and  are  to  be 
considered  as  complications. 

Eruption. — The  eruption  of  scarlet  fever  presents  many  peculiarities. 
It  is  simulated  by  many  other  eruptions  and  is  sometimes  so  atypical 
as  to  give  but  little  aid  in  making  a  diagnosis.  It  is  frequently  apparent  on 
the  neck  and  chest  within  twelve  hours  of  the  initial  symptoms  and  it  is 
commonly  present  on  the  morning  following  the  day  upon  which  the  ill- 
ness began.  In  rare  cases  it  is  delayed  for  more  than  thirty-six  hours,  but 
very  rarely  does  it  appear  after  the  fourth  or  fifth  day.  Among  108  hos- 
pital cases  Holt  found  that  the  rash  continued  from  three  to  seven  days  in 


Fig.  110 


105' 

104' 

2 103' 

< 

99° 

M 

E 

M     E 

M 

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M 

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M  1   E  1   m|   E 

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1 

Severe  septic  scarlet  fever  in  a  girl  of  nineteen  months,  beginning  mildly  but  being  complicated 
on  third  day  by  au  extensive  putrid  membranous  angina  and  rhinitis  and  signs  of  septic  infection, 
followed  by  pneumonia  and  death  on  the  twelfth  day.  Staphylococci  and  pneumococci  were  found 
in  large  numbers  in  the  throat  cultures  on  the  fourth  day  and  streptococci  on  the  sixth  day,  but  no 
BQebs-Loeffler  bacilli  were  present  at  any  time.  The  cervical  cellulitis  was  extensive ;  there  was 
extreme  opisthotonos  with  rigidity  of  the  legs  and  arms,  and  from  the  seventh  to  the  tenth  days 
there  were  several  general  convulsions. 

81.  The  rash  covers  the  face  and  whole  body  and  has  usually  reached 
its  height  at  the  end  of  twenty-four  hours.  A  peculiar  pallor  about 
the  mouth  is  a  characteristic  feature  of  the  disease. 

x\n  eruption  of  fine  vesicles  is  seen  in  rare  instances  and  occasionally 
a  blotchy  eruption  appears  on  the  face,  but  subsides  as  the  t\-pical  rash 
develops.  The  intense  itching  which  frequently  is  present  when  the 
rash  is  developing,  particularly  if  accompanied  bv  fine  vesicles,  some- 
times renders  the  appearance  of  the  case  quite  different  from  that  of 
the  regular  form.  The  rash  is  sometimes  very  faint.  In  some  mild  cases 
where  the  disease  is  not  suspected  and  medical  aid  is  not  sought  in  the 
early  stages  no  history  of  a  rash  can  be  obtained.  In  such  cases  the  rash 
is  usually  most  marked  in  the  axilloe  and  groins  or  other  folds  of  the 
skin.  x\t  times  it  is  irregular  in  its  distribution,  appearing  in  large, 
32 


498 


INFECTIOUS  DISEASES 


brinjht  patches  in  some  regions  and  l)eing  verv  faint  in  others.  In  some 
cases  as  it  does  not  appear  on  the  face  it  is  overlooked  unless  sought 
for  on  the  body.  When  the  rash  is  faint  or  uncertain,  a  hot  bath  or 
the  application  of  hot  water  to  a  part  of  the  body  may  cause  it  to  show. 
The  connnon  fear  of  the  laity  that  the  rash  will  not  come  out  well  or 
that  the  condition  is  unfavorable  when  the  rash  is  faint  is  not  well 
founded.  It  is  true  that  a  rash  that  suddenly  subsides  or  becomes 
faint  is  indicative  of  heart  failure,  but  when  the  symptoms  are  mild,  a 
faint  rash  need  cause  no  anxiety. 

On  the  other  extreme  from  these  mild  cases,  in  which  the  rash  is 
faint  or  the  irregular  ones  in  which  it  does  not  appear  in  typical  form, 


Fio.  in 


Well-marked  des(juamation  upon  the  dorsum  of  hands  and  fingers.    (Welch  and  Schamberg.) 


are  the  malignant  cases  in  which  the  rash  does  not  appear  or  appears 
in  hemorrhagic  form.  In  malignant  cases  the  child  sometimes  dies 
before  the  rash  appears;  in  others  the  rash  is  atypical  in  appearance  or 
actually  hemorrhagic.  These  latter  conditions,  however,  are  very  rare. 
There  may  be  considerable  edema  or  swelling  of  the  hands  and  face 
when  the  eruption  is  intense.  It  is  not,  however,  a  symptom  of  par- 
ticular gravity. 

Desquamation. — This  is  the  most  positive  sign  of  scarlet  fever,  for 
the  peculiar  extensive  desquamation  occurs  in  no  other  condition 
(Fig.  111).  It  rarely  begins  before  the  sixth  or  seventh  day  and  is 
sometimes  much  later  than  this  in  its  appearance.  There  is  frequently, 
therefore,  an  interval  between  the  disappearance  of  the  rash  and  the 
appearance  of  the  desquamation   when   the  skin  seems   normal.     A 


PLATE  XV. 


Scarlet  Fever  Desquamation.     Sixth  day  of  the  disease. 
(Welch  and  Schamberg.) 


SCARLET  FEVER 


499 


patient  seen  for  the  first  time  during  this  interval  may  mislead  a  physician 
if  the  case  has  been  mild  and  the  early  symptoms  have  been  obscure. 
When  the  skin  has  received  careful  attention  and  is  oiled  daily  the 
desquamation  may  be  almost  imperceptible  and  no  definite  scales  appear, 
as  they  form  with  the  oil  little  rolls  or  balls  as  the  skin  is  rubbed.  With 
such  care  there  is  but  little  dissemination  of  the  infection.  Desqua- 
mation of  the  trunk  and  extremities  is  not  infrequently  complete  in  a 
week,  and  there  is  sometimes  an  interval  of  several  days  before  desqua- 
mation of  the  feet  and  toes  begins.  Desquamation  of  the  fingers  usually 
begins  a  little  earlier  than  it  does  upon  the  feet,  partly  perhaps  because 


Fig.  112 


#  0i 

w 

i  a 

fi&$''^           il    P'                 M 

f 

§«;;  :i         ^i-^'            M      " 

.  M  ^i, '- 

RnHS 

.    M|p[j||>,,o W^-'-    ^1^ 

■^^BIP 

ft 

.:^HHV  1^   ^m 

Wk               i^'J'w^^^^^^k 

m^- 

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I'V^^^^^ 

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^-^mB^ 

'-^'•^^^^ 

^^^^^ 

w> 

Epidermal  glove-like  casts  from  a  fatal  case  of  scarlet  fever.     (Welch  and  Schamberg.) 


the  child  has  a  tendency  to  pick  continuously  at  them.  It  begins  first 
at  the  ends  of  the  fingers  (Fig.  111).  The  finger-tips  are  frequently 
found  soft  and  pink,  while  the  rest  of  the  hand  is  covered  with  a  grayish, 
thick  skin,  with  white  patches  where  the  skin  is  loosening.  As  a  rule, 
the  skin  is  picked  off  by  the  patient  in  little  patches  and  shreds,  but  cases 
are  on  record  in  which  quite  complete  casts  of  the  fingers  and  even  of 
the  hand  have  been  thrown  off  (Fig.  112).  This  desquamation  in 
shreds  and  strips  is  rarely  ever  seen  on  the  unexposed  portions  of  the 
body.  Desquamation  of  the  hands  and  feet  is  very  rarely  complete 
before  the  thirtieth  day  after  the  onset  of  the  disease.    It  more  frequently 


500  IXFECTIorS   DISKAShS 

rc(|uin's  fortv,  and  soinctiinos  persists  about  the  nails  until  the  end  of 
seven  or  ei«,dit  weeks,  as  mentioned  under  ehart  ( Fip;.  lOS).  Extensive 
descjuauiation  of  this  eharaeter.  and  particularlv  the  lanK>llar  des(|uania- 
tion  of  the  hands  and  feet,  is  so  eharaeteristie  of  searlet  fever  that 
a  (lia«,Miosis  may  l)e  made  from  it  even  when  the  early  symptoms  are 
ol)S(iu-e  and  uncertain.  Even  if  the  desciuamation  is  somewhat  uncer- 
tain, no  (liild  sliowiiiii'  it  should  In-  allowed  to  mingle  with  others. 

In  rare  eases  a  sei-ond  des<|uanuition  occurs  and  even  a  third,  which, 
of  cours<\  prolon<;s  the  course  of  the  disease.  These  secondary  desqua- 
mations are  usually  not  as  extensive  as  the  first.  They  commonly 
involve  a  i)orti(>n  of  the  hodv,  but  a  second  frcneral  descpiamation  of  the 
bodv  has  been  known  to  occur. 

The  Urine. — In  the  Paris  Theses  of  lOOo,  Lahde  reports  observations 
made  upon  the  urine  in  scarlet  fever  and  diphtheria.  In  scarlet  fever 
diminished  secretion  continues  during  the  first  six  days  of  the  eruption, 
but  there  is  a  sudden  increase  at  the  ei(;hth  or  ninth  day.  The  acidity 
is  decidedlv  increased.  The  minimum  excretion,  of  lU'cu  occurs  at  the 
fifth  day  of  the  eruption.  There  is  then  usually  a  sudden  increase 
followecl  by  a  gradual  fall.  The  presence  of  urobilin  and  indican  is 
rare  in  scarlet  fever,  but  is  constant  in  diphtheria.  The  diazo  reaction 
is  ocr-asionally  found  in  scarlet  fever,  but  is  never  seen  in  diphtheria. 
Duriuf  the  febrile  stage  a  slight  amount  of  albumin  is  fouud  frecpiently 
in  the  urine  and  sometimes  blood  and  hyaline  casts.  This  is  most 
commonly  febrile  albuminuria,  which  usually  disappears  as  the  fever 
subsides.  Except  in  the  more  severe  forms,  suppression  is  rare  and 
dropsv  more  so.  These  symptoius  usually  subside  as  the  fever  falls. 
The  kidney  symptoms  at  this  stage  rarely  prove  serious.  They  may, 
however,  do  so  and  always  demand  attention.  The  more  serious  kidney 
symptoms  occur  later  and  will  be  considered  as  complications. 

The  Tonxjuc. — The  term  "strawberry  tongue"  has  misled  many  young 
l^ractitioners.  One  author  describes  it  as  a  white-coated  tongue,  showing 
prominent  red  papilhe;  while  another  says  that  it  is  a  rough,  red  tongue, 
presenting  dark-red  papilhe.  These  two  conditions  are  very  different, 
so  different  in  fact  that  they  cannot  be  diagnostic  of  the  same  path- 
ological condition.  Fu.ssell  has  recently  cjuoted  the  description  of  the 
strawberry  tongue  given  by  over  twenty  authorities,  which  show  the 
greatest  divergence  of  opinion.  "^Fhe  consensus  of  opinion  would  seem 
to  be  that  the  term  should  be  applied,  not  to  the  white-coated  tongue, 
frerpiently  seen  in  the  first  stage  of  scarlet  fever,  but  to  the  red,  rough 
tongue  commonly  seen  on  or  after  the  fourth  day,  the  papilhe  being  dark 
red  in  color.  There  are  two  facts  worthy  of  consideration:  A  white 
tongue  with  red  papilhe  is  seen  in  numerous  conditions  and  is  not 
confined  to  scarlet  fever;  the  strawberry  is  not  a  white  fruit  with  red 
.seeds,  but  a  dark-red  fruit  with  a  rough  surface.  It  is  unwise,  therefore, 
to  apply  the  term  strawberry  to  a  white  tongiie,  and  still  more  unwise 
to  lay  stress  on  such  a  tongue  as  a  .symptom  of  importance  in  making  a 
diagnosis  of  scarlet  fever. 

The  true  strawberry  tongue   was   originallv   described   bv   Flint   as 


SCARLET  FEVER 


501 


follows:  "The  tongue  early  in  the  disease  generally  is  coated.  While 
the  coating  remains,  frequently  the  papillae  projecting  through  it  have 
the  appearance  of  red  points;  the  surface  of  the  tongue  looks  as  if 
cayenne  pepper  or  red  sand  had  been  sprinkled  over  it.  This  is  seen 
in  other  affections.  Another  appearance  is  quite  distinctive  of  scarlet 
fever.  In  the  progress  of  the  disease  the  coating  exfoliates,  leaving  the 
surface  of  the  tongue  clean  and  reddened;  and  the  papilhe  being  enlarged, 
the  appearance  is  strikingly  like  that  of  a  red  strawberry.  The  straw- 
berry-red tongue  is  a  pathognomonic  symptom;  it  is  peculiar  to  the 
disease.     It  is  often  but  not  uniformly  present." 

Constitutional  Symptoms. — The  constitutional  symptoms  of  scarlet 
fever  are  in  no  way  characteristic.  They  vary  with  the  severity  of  the 
attack  and  with  the  presence  or  absence  of  complications.  There  is 
occasionally  an  indefinite  premonitory  stage  in  which  the  child  seems 
ill,  but  shows  no  characteristic  symptoms.  In  a  recent  case  of  my  own 
(see  Fig.  107)  there  was  so  marked  a  change  in  the  color  and  appear- 
ance of  the  child  that  the  mother  took  the  temperature  at  noon  and 
found  it  normal.  At  five  o'clock  there  was  vomiting  and  the  tempera- 
ture was  102.2°  F.  The  rash  was  present  on  the  following  morning. 
Headache  is  frequently  present,  but  is  not  constant.  There  may  be 
aching  of  the  limbs  and  muscular  pains,  but  these  are  also  not  constant 
symptoms. 

Complications  and  Sequelae. — The  common  complications  of  scarlet 
fever  are  angina,  otitis,  adenitis,  arthritis,  and  nephritis.  The  most 
common  sec[uelte  are  nephritis  and  deafness. 

Angina. — Except  in  the  mildest  cases  the  throat  always  shows  more 
or  less  pathological  change.  A  catarrhal  condition  of  the  throat  is 
normal  to  scarlet  fever,  but  membranous  exudates  and  gangrene  are 
not  essential  to  it.  Small  white  or  yellowish  spots  similar  to  those  seen 
in  tonsillitis  sometimes  appear  before  the  eruption  and  may  readily 
lead  to  a  diagnosis  of  simple  tonsillitis.  These  spots  may  coalesce  to 
form  membranes,  or  they  may  wholly  disappear  after  two  or  three  days. 
This  simple  angina  cannot  be  considered  a  complication.  Two  other 
forms  of  angina,  however,  frequently  occur  and  are,  strictly  speaking, 
complications.  These  are  the  membranous  angina  and  gangrenous 
angina. 

Bacteriologists  have  settled  that  with  few  exceptions  the  angina  of  the 
early  stages  is  pseudodiphtheria,  that  of  the  late  stages  true  diphtheria. 
While  primary  pseudodiphtheria  is  a  mild  flisease,  the  death  rate  being 
rarely  over  5  per  cent.,  secondary  pseudodiphtheria  is  very  dangerous  and 
fatal.  The  membrane  may  appear  in  the  throat  on  the  first  or  second 
day,  but  is  not  usually  seen  before  the  third  day.  It  is  generally  confined 
to  the  tonsils,  but  frequently  fills  the  throat  and  nasopharynx.  It  shows 
a  tendency  to  invade  the  ears  and  nose  and  to  shun  the  larynx.  It 
reaches  its  height  about  the  sixth  or  seventh  day.  It  frequently  presents 
all  the  local  characteristics  of  diphtheria,  together  with  the  general 
symptoms  of  septicemia.  The  pseudomembranes  vary  considerably  in 
color.    They  are  commonly  of  a  gray  or  greenish  cast,  but  are  occasion- 


502  INFECT  10 IS  DISEASES 

allv  clear  and  white.  In  severe  cases  the  exudate  is  sometimes  black. 
Even  when  not  strictly  gangrenous,  the  breath  may  be  of  a  foul  and 
sickening  odor  and  there  is  a  thin,  fetid  tlischarge  from  the  throat  and 
nose.  There  is  frequently  edema  in  and  about  the  nasopharynx  which 
renders  mouth  l)rcathing  necessary.  These  changes  in  the  throat  arc 
invariably  accompanied  by  swelling  of  the  lymph  nodes  and  cellulitis. 
When  the  throat  symptoms  are  marked  the  constitutional  symptoms  arc 
also  severe  its  a  rule,  owing  to  general  septic  infection  in  which  strepto- 
cocci play  the  most  important  part.  When  the  throat  symptoms  are 
.severe,  otitis  almost  always  occurs  and  pneumonia  and  nephritis  arc 
particularly  common  (Figs.  109  and  110). 

Without  a  bacterial  examination  it  is  frequently  impossible  to  dis- 
tinguish between  membranes  due  to  the  Klebs-IiOeffler  bacillus  and 
those  resulting  from  some  other  germ.  As  a  rule,  streptococcus  anginas 
are  accomjxuiied  by  more  inflammation,  edema,  and  redness,  and  by 
greater  infiltration  of  the  tissues  of  the  neck  than  in  true  diphtheritic 
angina.  In  the  streptococcus  disease  there  is  a  strong  tendency  to 
invade  the  ears,  while  in  diphtheria  the  larynx  is  more  commonly  the 
direction  of  extension.  The  exciting  cause  of  membranous  inflam- 
mation is  usually  the  streptococcus  pyogenes.  It  is  occasionally  asso- 
ciated with  the  staphylococcus  aureus  or  albus,  but  the  streptococcus  is 
the  more  commonly  observed.  It  occurs  not  only  in  the  pseudo- 
membranes  and  the  tissues  under  it,  but  is  found  in  the  blood  in  large 
numbers.  Through  the  agency  of  the  toxins  which  it  generates  it  is 
unquestionably  the  cause  of  many  of  the  complications  and  of  general 
septicemia. 

The  pseudomembranes,  which  appear  late  in  the  disease,  are  usually 
associated  with  the  Klebs-Loefflcr  bacillus.  Diphtheria  is  in  the  fullest 
sense  of  the  word  a  complication,  and  is  not  an  essential  symptom  of 
scarlet  fever. 

Gangrenous  angina  is  the  worst  phase  of  the  scarlatinal  sore  throat. 
The  symptoms  already  described  are  exaggerated.  The  odor  of  the 
breath  is  very  offensive.  The  swelling  and  obstruction  in  the  throat  are 
extreme  and  the  infiltration  of  the  lymph  nodes  is  very  great.  The 
throat  is  filled  with  a  pultaceous  mass  of  sloughing  tissue,  of  gray  or 
blackish  color.  The  discharge  from  the  throat  and  nose  may  be  purulent 
or  thin  and  fetid.  The  prostration  and  symptoms  of  general  infection 
are  extreme;  the  case  usually  terminates  fatally.  In  extreme  cases  the 
slough  sometimes  involves  a  bloodvessel  and  sudden  death  may  occur 
from  hemorrhage. 

Otitts. — The  most  common  complication  of  scarlet  fever  next  to 
angina  is  otitis.  Its  effects  are  often  serious,  for  it  is  a  common  cause 
of  deaf-mutism.  It  results  from  the  extension  of  the  inflammation  from 
the  throat  through  the  Eustachian  tubes.  The  tendency  to  ear  involve- 
ment varies  with  diflVrent  epidemics,  but  it  is  more  common  in  young 
patients.  It  does  not  usually  occur  until  the  second  w'eek,  and,  as  a 
rule,  involves  both  ears.  Its  presence  may  be  indicated  by  earache  and 
an  increase  in  the  fever,  but  frequently  a  discharge  is  the  first  indication 


SCARLET  FEVER  503 

that  the  ears  are  involved.  The  process  is  prone  to  be  a  destructive  one 
and  to  result  in  long-continued  suppuration.  It  sometimes  leads  to  a 
rapidly  fatal  meningitis.  When  it  occurs  before  the  fever  has  subsided 
it  may  produce  no  symptom  and  the  child  may  complain  of  no  pain. 
When  it  occurs  as  a  later  complication  its  advent  is  usually  marked  by 
fever  and  increased  pulse  rate.  When  the  membrane  does  not  rupture 
and  the  tension  in  the  cavity  of  the  middle  ear  is  very  great,  nervous 
symptoms  may  become  pronounced,  muscular  rigidity,  opisthotonos, 
and  even  convulsions  being  possible.  When  destructive  ear  changes 
occur  in  early  childhood,  deaf-mutism  is  a  probable  result.  Among 
5613  deaf-mutes  whose  cases  were  investigated  by  May,  it  was  found 
that  572  cases  resulted  from  the  otitis  of  scarlet  fever. 

Adenitis  and  Cellulitis. — Adenitis  and  cellulitis  are  not  unusual 
results  of  streptococcic  invasion  of  the  throat.  Not  only  are  the  lymph 
nodes  themselves  enlarged,  but  there  is  more  or  less  inflammatory 
edema  of  the  surrounding  tissues.  That  this  is  due  to  secondary  infec- 
tion is  shown  by  the  fact  that  the  streptococci  are  found  in  abundance 
in  both  the  nodes  and  edematous  tissue  around  them.  Enlargement 
of  the  nodes  may  be  detected  during  the  first  week,  but  serious  cellulitis 
does  not,  as  a  rule,  occur  until  later  in  the  disease.  Suppuration,  slough- 
ing, or  even  gangrene  may  occur.  The  cellulitis  may  be  localized  to  a 
small  area  around  the  enlarged  lymph  nodes  or  may  be  general.  As 
soon  as  it  becomes  marked  the  head  is  apt  to  be  drawn  backward.  In 
extreme  cases  this  is  so  conspicuous  a  symptom  as  to  lead  to  a  suspicion 
of  cerebrospinal  disease.  Dyspnea  is  not  uncommon.  An  extreme 
suppurating  adenitis  is  a  complication  of  the  utmost  gravity.  It  may 
lead  to  death  by  involving  important  vessels  or  by  the  slower  process 
of  general  infection.  As  it  usually  accompanies  an  extreme  and  serious 
throat  complication,  the  prognosis  is  always  bad. 

Arthritis. — Scarlatinal  rheumatism  has  been  relegated  by  modern 
methods  of  investigation  to  the  list  of  rare  diseases.  The  joint  affections 
which  occur  during  the  course  of  scarlet  fever  are,  however,  not  un- 
common, but  they  are  proved  to  be  due  to  more  than  one  pathological 
condition.  True  rheumatic  arthritis  is  one  of  the  rarest  of  the  joint 
affections  complicating  scarlet  fever.  The  most  common  joint  lesion 
of  scarlet  fever  is  synovitis,  and  the  next  most  common  is  probably 
septic  arthritis.  In  classifying  these  various  lesions,  Marsden,  of 
London,  uses  Ashby's  classification,  slightly  changing  the  nomenclature 
as  follows:  (1)  scarlatinal  synovitis;  (2)  septic  arthritis;  (3)  acute  or 
subacute  rheumatic  synovitis;  (4)  tuberculous  arthritis. 

Scarlatinal  synovitis  usually  appears  early  in  the  second  week,  con- 
tinues for  three  or  four  days,  and  disappears.  Suppuration  is  rare;  it 
is  seldom  seen  under  four  years.  The  onset  is  usually  acute  and,  as  a 
rule,  the  attack  runs  an  acute  course.  In  some  cases  there  is  nothing 
to  be  found  save  pain  on  movement,  or  tenderness;  in  others  the  whole 
of  the  hand  is  red  and  swollen.  Between  these  two  conditions  all  grades 
are  met.  The  hands  and  wrists  are  the  favorite  site.  They  were  attacked 
in  no  less  than  72  out  of  one  series  of  100  cases.    Any  joint,  however, 


504  INFECTIOrS  DISEASES 

niav  he  affected.  Septic  arthritis  is  frequently  known  as  pyemic  ar- 
thritis. In  this  conchtion  the  hirjjje  joints  are  usually  involved  and  the 
lesions  are  a])t  to  he  nuiltijjle.  The  condition  is  always  a  ^rave  one, 
as  sup])uration  and  injury  to  the  joint  are  conunon.  True  rheumatism 
occurs  third  in  order  of  fretjuency.  It  appears  late  in  the  course  of  the 
disease  and  rarely  proves  serious.  The  attack  is  almost  invariahly 
snl)acut(>  in  character  and  continues  for  a  few  days.  Evidence  of  heart 
involvenuMit  is  not  unconnnon  and  a  permanent  nuirmur  is  sometimes 
left  hehind.     Antirheumatic  treatment  usually  i,nvcs  prompt  relief. 

Xephrltis. — During  the  acute  stage,  particularly  when  the  fever  is 
high,  a  slight  amount  of  alhumin  is  usually  found.  It  is  commonly  only 
a  slight  fel)rile  alhnmimu'ia  due  to  degenerative  nephritis  which  suhsides 
as  the  temperature  falls.  In  the  grave  type  kidney  lesions  may  occur, 
to  which  the  term  septic  nephritis  has  heen  given.  The  urine  contains 
alhumin,  hut  l)lood  and  casts  are  not  necessarily  present,  neither  do  the 
rational  symptoms  of  uremia  appear. 

The  most  characteristic  and  c-ommon  kidney  lesion  is  postscarlatinal 
nej)hritis,  which  is  a  diffuse  nephritis.  It  usually  develops  during  the 
third  or  fourth  week.  There  may  be  no  interval  of  apyrexia  between 
the  kidney  attack  and  the  nephritis.  It  may  be  so  mild  as  to  almost 
escape  notice,  or  it  may  be  so  severe  as  to  cause  death.  Recovery  may 
be  complete  or  incomplete.  The  first  symptom  to  he  noticed  is  usually 
edema  of  the  face,  which  is  fretjuently  accompanied  by  feverishness  and 
restlessness.  Dropsy  and  all  the  characteristic  symptoms  of  acute 
nephritis  rapidly  develop.  The  urine  usually  shows  a  small  amount  of 
alhumin  for  a  few  days  before  the  advent  of  definite  symptoms.  As  the 
disease  develops  the  urine  becomes  scantv  and  high  colored  and  may 
be  completely  suj)pressed.  It  contains  a  large  amount  of  albumin  and 
is  loaded  with  blood  cells  and  casts.  The  first  evidence  of  albumin  after 
the  second  week  of  scarlet  fever  should  be  a  warning  of  danger,  and 
should  receive  immediate  attention. 

Daily  examination  of  the  urine  is  desirable.  It  is  a  wise  plan  to  take 
to  the  house  of  the  patient  test  tubes,  a  spirit  lamp,  and  a  bottle  of 
nitric  acid.  A  pocket  test  ca.se  is  useful  in  these  cases.  An  examination 
may  thus  be  made  daily  with  hut  little  loss  of  time,  as  the  early  detection 
of  alhumin  always  repays  for  the  trouble  taken. 

Other  Complications. — Numerous  other  pathological  conditions  may 
occur  as  complications  or  sequehne,  hut  are  less  common  than  those 
mentioned.  Pneumonia,  although  commonly  found  at  the  autopsy  of 
patients  who  have  died  with  septic  symptoms,  is  frequently  not  recog- 
nized before  death.  Pleuropneumonia  occasionally  occurs  when  there 
is  marked  septic  infection.  Either  simple  or  pleuropneumonia  is  a 
grave  complication  and  usually  determines  a  fatal  result.  Empyema 
is  also  a  po-ssibility  in  septic  cases  or  as  a  sequel  of  pleuropneumonia. 
When  there  is  marked  nephritis,  serous  effusion  into  the  pleural  cavity 
may  occur,  and  edema  of  the  lungs  is  not  uncommon  as  a  terminal 
symptom.  Endocarditis  and  pericarditis,  though  uncommon,  are  some- 
times encountered.     Murmurs  are  occasionally  heard  during  the  cour.se 


SCARLET  FEVER  5O5 

of  the  disease,  which  disappear  as  the  active  symptoms  subside.  Perma- 
nent organic  lesions  sometimes  develop  in  conjunction  with  the  late 
kidney  complications.  The  various  serous  membranes  are  occasionally 
involved.  Endocarditis  is  rather  more  prone  to  be  of  the  malignant  tvpe 
in  scarlet  fever  than  it  is  in  simple  rheumatic  cases.  As  in  all  diseases 
marked  by  high  temperature  or  septic  infection,  myocarditis  is  not 
uncommon,  and  acute  dilatation  of  the  heart  is  sometimes  encountered. 

Xervous  symptoms  are  less  frecjuent  than  might  be  expected  in  a 
disease  so  often  septic  in  its  nature.  A  convulsion  in  rare  cases  occurs 
as  an  initial  symptom.  Convulsions  due  to  uremia  sometimes  occur 
in  the  late  stages.  In  a  recent  case  under  my  observation,  the  child  for 
thirty-six  hours  showed  marked  opisthotonos.  There  was  contracture 
of  the  muscles  of  the  extremities,  with  repeated  convulsive  attacks  of 
the  nature  of  tetany.  These  convulsions,  some  of  them  severe,  were 
precipitated  by  anything  which  irritated  the  child — such  as  attempts  at 
feeding  or  sjTinging  the  nose.  ^Meningitis  is  rare,  but  retraction  of  the 
head  due  to  swollen  l^Tiiph  nodes  sometimes  leads  to  the  belief  that  it 
is  developing.  It  may  occur  as  the  sequel  of  otitis  and  even  as  a  com- 
plication of  nephritis.  Chorea  is  very  rare  even  when  the  case  is  com- 
plicated by  diphtheria.     Peripheral  paralysis  is  also  rare. 

Vomiting  usually  occurs  at  the  outset  and  the  stomach  is  sometimes 
irritable  for  two  or  three  days,  but  grave  gastroenteric  disturbance  is 
not  common,  except  in  malignant  cases.  Loss  of  appetite  durincr  the 
period  of  fever  is  not  uncommon,  and  feeding  is  a  difficult  problem. 
Catarrhal  stomatitis  is  of  frequent  occurrence,  and  this,  together  with 
sore  throat,  frequently  leads  the  child  to  refuse  food  when  it  mio-ht 
otherwise  accept  it. 

Except  in  very  mild  cases  leukocytosis  is  present.  Even  in  such  cases 
it  may  occtir  to  a  slight  degree.  Whenever  suppuration  occurs  the 
leukoc\i:osis  increases.  A  marked  leukoc}i;osis,  therefore,  is  to  be  expected 
in  complicated  cases.  The  blood  conditions  in  this  disease  are  fullv 
described  in  the  Section  on  the  Blood.  Purpura  hemorrhagica  and 
peculiar  attacks  of  superficial  symmetrical  gangrene  have  been  reported 
in  a  very  few  cases.  The  thighs  and  arms  are  most  commonly  affected 
in  this  latter  disease,  which  runs  a  rapid  and  usually  a  fatal  course. 

Other  Exanthemata  as  Complications. — Scarlet  fever  may  be  com- 
plicated by  any  of  the  other  infectious  diseases.  After  diphtheria, 
measles  is  probably  the  most  frequent  of  these,  but  chickenpox,  small- 
pox, typhoid  fever,  and  erysipelas  have  been  reported  as  occurring 
coincidently  with  scarlet  fever.  AMien  two  of  these  diseases  occur 
synchronously,  the  symptoms  are  obscure  and  often  puzzling.  As  a 
rule,  however,  the  onset  of  one  disease  occurs  as  the  other  is  beginning 
to  subside,  and  the  two  eruptions  succeed  each  other.  The  tendency 
of  diphtheria  to  complicate  scarlet  fever  has  already  been  dwelt  upon. 
It  usually  occurs  after  the  scarlet  fever  has  partially  run  its  course,  but 
I  have  seen  it  precede  the  scarlet  fever. 

Diagnosis. — In  tvpical  cases  the  diagnosis  of  scarlet  fever  is  very  easy. 
It  is  the  irreo-ular  forms  which  cause  uncertaintv.     In  all  the  exanthem- 


50G  INFECTIOUS  DISEASES 

ata  it  is  usually  peculiarities  in  the  eruption  which  render  the  diagnosis 
most  (liHicult/  In  doubtful  cases  it  is  iiiipossililc  to  make  a  diaonosis 
from  the  eruption  alone.  There  are  many  simple  rashes  due  to  digestive 
disturbance  or  mild  infection  which  closely  simulate  scarlet  fever.  It 
is  occasionally  necessary  to  wait  for  the  period  of  des(iuamation  before 
a  positive  diagnosis  can  be  made.  As  a  rule,  too  nnich  attention  is 
devoted  to  the  eruption  to  the  exclusion  of  other  symptoms.  The 
eruption  produced  in  some  cases  by  belladonna  or  atropine,  cjuinine, 
ant i pyrin,  and  occasionally  by  diphtheria  antitoxin  is  much  like  that 
of  scarlet  fever.  Due  consideration  of  the  accompanying  symptoms, 
however,  is  usually  sufficient  to  prevent  error  in  diagnosis.  Certain 
types  of  urticaria  and  simple  eruptions  of  that  class  are  also  occasionally 
very  suspicious.  If  accompanied  by  digestive  disorders  with  vomiting 
and  fever,  the  diagnosis  is  sometimes  very  difficult.  An  erythema 
occasionally  accompanies  typhoid  fever,  which  may  lead  to  an  erroneous 
diagnosis.  '  There  have  been  certain  epidemics  of  influenza  in  which  a 
scarlatiniform  erythema  has  caused  much  anxiety  to  the  medical 
attendant.  The  sudden  onset  of  fever,  with  sore  throat  and  perhaps 
nausea  followed  by  a  more  or  less  extensive  erythema  is  a  picture  very 
suggestive  of  scarlet  fever.  In  my  experience  the  eruption  in  these  cases 
has  been  coarser  than  that  of  scarlet  fever  and  there  has  been  less  diffuse 
redness.  Occasionally,  however,  a  uniform  erythema  without  the  red 
pinhead  points  has  been  present,  "(irippe  with  a  rash"  presents  some 
very  difficult  cases  for  diagnosis.  The  pulse  in  scarlet  fever  is  more 
nipid  than  in  influenza. 

Occasionally  the  rash  of  scarlet  fever  is  in  places  blotchy.  Usually, 
however,  if  search  is  made  areas  of  reddened  skin  will  be  found  dotted 
with  the  characteristic  pinhead  spots.  These  areas  are  more  apt  to 
be  found  in  the  groins  and  axilhv  and  in  folds  of  the  skin.  When  the 
rash  is  faint,  a  hot  bath  may  sometimes  render  the  diagnosis  easy.  The 
same  result  may  l)e  accomplished  locally  by  placing  cloths  wrung  out 
of  hot  water  for  a  few  minutes  across  the  abdomen  or  chest.  When 
the  temperature  is  very  high  in  some  cases  of  the  malignant  type  the 
rash  is  hemorrhagic.  This,  together  with  the  nervous  symptoms,  may 
lead  to  the  suspicion  of  epidemic  cerebrospinal  meningitis.  A  white 
line  appearing  at  the  junction  of  the  finger-nail  and  the  pulp  of  the 
finger  is  considered  by  McCoUom  a  valuable  sign  of  scarlet  fever. 
Desquamation  is  undoubtedly  the  most  distinctive  feature  of  scarlet 
fever,  but  it  is  unfortunately  a  very  late  one.  A  rash,  if  it  is  ever  so 
mild,  if  followed  by  characteristic  (les(|uamation  of  the  hands  and  feet, 
may  be  consideretl  as  certainly  scarlatinal.  If  no  desquamation  appears 
after  careful  watching,  it  is  almost  equally  certain  that  the  case  was  not 
scarlet  fever.  Attention  is  called  on  another  page  to  the  fact  that 
scarlet  fever  is  sometimes  mistaken  during  the  first  twelve  or  twenty- 
four  hours  for  tonsillitis.  The  early  throat  symptoms  of  scarlet  fever 
are  often  very  similar  to  those  of  diphtheria.  In  many  cases  it  is  im- 
possible to  make  a  diagnosis  without  a  bacterial  culture.  The  presence 
of  diphtheria  at  the  outset  is  entirely  possible,  but  in  the  large  proportion 


SCARLET  FEVER  5O7 

of  cases  the  exudates  of  the  early  stage  are  pseudodiphtheria.  In  scarlet 
fever  urobilin  and  indican  are  rarely  found  in  the  urine,  but  are  constantly 
found  in  diphtheria.  In  scarlet  fever  the  diazo  reaction  can  frequently 
be  obtained,  but  never  in  diphtheria. 

The  diagnosis  between  scarlet  fever  and  measles  rarely  offers  any 
difficulties.  The  prolonged  prodromal  stage  of  measles,  with  its  coryza, 
cough,  and  suffusion  of  the  eyes,  followed  by  a  blotchy,  slow-spreading 
eruption,  forms  a  picture  so  characteristic  that  it  is  rarely  mistaken  for 
scarlet  fever.  This  is  not  as  true,  however,  regarding  rubella.  Some 
cases  of  this  disease  are  very  difficult  to  distinguish  from  scarlet  fever. 
On  the  other  hand,  mild  scarlet  fever  is  not  infrequently  mistaken  for 
German  measles.  In  rubella  there  are  usually  no  prodromal  symptoms. 
Vomiting,  sore  throat,  fever,  and  rapid  pulse  are  all  wanting.  The 
eruption  is  the  first  symptom  to  appear.  It  appears  first  on  the  face 
and  looks  much  like  that  of  scarlet  fever,  but  is  usually  less  markedly 
punctiform.  It  is  more  diffuse  and  a  little  lighter  in  color.  If  the  whole 
body  is  examined  areas  will  usually  be  found  in  which  the  eruption  is 
coarser  and  loses  its  scarlatiniform  aspect.  Desquamation  is  absent  or 
appears  in  very  fine,  branny  scales.  Enlargement  of  the  cervical  and 
auricular  lymph  nodes  is  almost  invariably  present  in  rubella,  but  is 
rare  in  scarlet  fever.  The  most  important  point  in  differential  diagnosis 
is  the  absence  in  rubella  of  constitutional  symptoms.  Although  very 
mild  cases  of  scarlet  fever  are  sometimes  seen,  a  rash,  as  bright  and 
distinct  as  that  of  the  average  case  of  rubella,  is  invariably  accompanied 
for  a  day  or  two  at  least  by  distinctive  constitutional  symptoms.  The 
pulse  is  rapid  and  the  temperature  rarely  below  102°  F. 

Recurrence  and  Relapse. — ^^^lile  second  attacks  of  scarlet  fever  some- 
times occur  they  are  extremely  rare,  probably  more  so  than  in  the  case 
of  any  other  infectious  disease.  So  many  other  rashes  simulate  that  of 
scarlet  fever  that  errors  in  diagnosis  are  not  difficult.  The  reports  of 
second  attacks  must  be  received  with  much  reservation,  and  are  to  be 
unreservedly  accepted  only  from  competent  and  cautious  observers. 

Relapses  are  more  common  than  second  attacks.  They  result  from 
autoinfection  and  occur  during  the  second  or  third  week.  They  are 
similar  in  their  nature  to  the  relapses  of  typhoid  fever.  They  sometimes 
pursue  the  course  of  the  primary  disease.  As  in  the  relapses  of  typhoid 
fever,  they  are  frequently  less  severe  than  the  primary  attack,  but  this 
is  not  always  the  case.  These  true  relapses  should  not  be  mistaken  for 
those  cases  in  which  the  rash  subsides  for  a  few  days  and  then  reappears. 
This  latter  condition  sometimes  occurs  with  the  increased  fever  which 
accompanies  a  late  complication.  I  have  seen  a  rash  which  had  almost 
disappeared  reappear  very  distinctly  upon  the  administration  of  a  hot 
bath  and  continue  clear  for  more  than  twenty-four  hours. 

Prognosis. — After  a  study  of  a  large  number  of  American  and  European 
cases,  Holt  concludes  that  the  general  mortahty  of  scarlet  fever  may  be 
assumed  to  be  from  12  per  cent,  to  14  per  cent.,  while  under  five  years 
it  is  from  20  per  cent,  to  30  per  cent.  It  is  much  lower  in  private  practice 
than  in  hospitals,  and  varies  greatly  in  different  epidemics.     Statistics 


50S  IXFECTIOrS  DISEASES 

as  to  general  mortality  rates  give  but  little  practical  aid  in  determining 
tlu*  prognosis  of  any  particular  casr.  The  two  most  important  general 
factors  are  the  age  of  tlie  child  and  the  charac-tcr  of  tlie  prevaiHng 
epidemic.  The  younger  the  patient,  the  greater  the  danger.  The 
majority  of  fatal  cases  occur  in  children  under  seven  years.  In  a  study 
of  1000  cases,  J.  H.  McCollom  found  the  mortality  of  all  cases  to  be 
9.S  per  cent.  Scarlet  fever  unaccompanied  caused  58  deaths;  l)roncho- 
pncumonia,  1.');  (iiphthcria  and  scarlet  fever  coml)inc(l,  10;  (Hphthcria 
alone,  9;  pneumonia,  4;  scarlet  fever  and  erysipelas,  1;  tuberculous 
meningitis,   1. 

Death  may  occur  at  any  stage  from  the  outset  until  months  after  the 
subsidence  of  acute  symptoms.  Death  during  the  first  few  davs  usually 
occurs  only  in  the  malignant  cases  in  which  the  ])atient  is  overwhelmed 
by  the  poison  of  the  disease  itself.  Death  in  these  cases  is  due  strictly 
to  scarlet  fever.  Death  during  the  second  and  third  weeks  may  also 
result  from  the  intensity  of  the  scarlatinal  poison,  but  is  more  commonly 
due  to  some  complication,  especially  diphtheria,  pneumonia,  and  acute 
nephritis.  It  may  result  also  from  intense  septic  infection  due  to  severe 
throat  and  glandular  involvement,  death  being  due  to  exhaustion. 
Death  after  the  third  week  is  usually  due  to  postscarlatinal  nephritis. 
This  may  occur  without  reference  to  the  severity  of  the  early  stages 
and  may  be  postponed  for  weeks  or  months  after  the  disease  has  run 
its  course.  Prognosis  is  renderetl  unfavorable  by  the  appearance  of 
the  following  symptoms,  the  gravity  being  in  proportion  to  their  severity: 
violent  onset,  high  temperature,  convulsions,  extensive  pseudomem- 
branes,  gangrenous  pharyngitis,  diphtheria,  croup,  pneumonia,  excessive 
cellulitis,  superficial  gangrene,  nephritis,  and  exhaustion,  with  general 
septic  symptoms.  The  prognosis  in  uncomj)licate(l  ca'^es  in  older  cliil- 
dren,  even  when  the  disease  runs  an  active  course,  is  good. 

Prophylaxis. — ^In  few  other  diseases  are  preventive  measures  so  pro- 
ductive of  good  results  as  in  scarlet  fever.  Its  spread  can  be  more 
readilv  controlled  than  can  that  of  most  of  the  other  infectious  diseases. 
The  measures  necessary,  however,  to  that  end  are  many  in  number 
and  very  complex,  and  demand  on  the  part  of  the  practitioner  much 
thought  and  perseverance.  When  we  consider  the  high  mortality  of 
scjirlet  fever  and  the  grave  secpiehr  in  those  who  survive,  we  are 
forced  to  feel  that  neglect  of  preventive  measures  is  little  short  of 
criminal. 

Every  child  who  is  known  to  have  been  exposed  to  scarlet  fever  should 
be  isolated.  It  is  true  that  the  disease  is  not  contagious  during  the  period 
of  incubation.  It  is  doubtful,  indeed,  whether  it  is  contagious  before 
the  appearance  of  the  eruption.  Children  in  contact  with  scarlet  fever 
patients  for  several  hours  after  the  initial  vomiting  do  not  always  contract 
the  disease.  There  may  be  exceptions,  however,  to  the  rule  and  expo- 
sure during  an  early  stage  may  in  some  cases  be  followed  by  serious 
results.  The  fact,  however,  that  as  a  rule  contagion  is  not  active  until 
the  eruption  has  developed  is  an  extremely  important  one.  We  have 
thus  in  scarlet  fever  a  distinct  advantage  over  measles,  for  in  the  latter 


SCARLET  FEVER  599 

disease  the  period  of  contagion  begins  two  or  three  days  before  the 
appearance  of  the  eruption. 

The  question  of  sending  the  other  children  away  from  home  is  often 
a  serious  one.  The  decision  must  rest  largely  on  the  time  of  the 
exposure.  If  the  exposure  occurred  before  the  appearance  of  the 
eruption,  there  may  be  little  fear  that  the  disease  has  been  contracted. 
If  exposure  occurred  during  the  stage  of  eruption,  the  probability  of 
illness  will  be  very  great.  If  the  patient  is  isolated  soon  after  the  initial 
symptoms  have  appeared,  other  children  in  the  family  are  very  unlikely 
to  have  taken  the  disease  from  him. 

Whatever  may  be  thought  of  the  propriety  of  isolation  during  the 
period  of  incubation,  there  can  be  no  doubt  of  its  importance  after  the 
first  symptoms  have  appeared.  It  should  be  complete  with  no  relax- 
ation. The  patient  is  dangerous  to  others  as  long  as  the  slightest  des- 
quamation continues  on  any  portion  of  the  skin.  The  duration  of  this 
period  is  extremely  variable,  and  the  most  common  error,  perhaps,  con- 
sists in  being  guided  by  a  fixed  number  of  days.  The  conventional  fortv 
days  is  to  be  regarded  as  only  approximate.  It  is  rarely  too  long. 
Desquamation  is  liable  to  persist  in  small  areas  of  the  body  after  its 
disappearance  from  other  portions.  These  circumscribed  areas  are  most 
frequently  found  about  the  flexures  of  the  joints  and  about  the  finger-nails 
after  desquamation  has  disappeared  from  every  other  part  of  the  body. 
There  can  be  no  more  dangerous  place  for  such  persistence,  for  the 
scales  are  liable  to  fall  on  any  article  which  the  fingers  may  touch  and 
may  hence  be  conveyed  to  a  distance.  There  are  many  authentic  cases 
of  conveyance  of  the  disease  through  letters  written  by  desquamating 
hands.  I  have  known  of  such  an  occurrence,  the  letter  going  several 
hundred  miles  through  the  mails.  The  hands  and  fingers  should  be 
particularly  scrutinized  before  the  quarantine  is  raised. 

The  subject  of  secondary  and  tertiary  desquamation  is  interesting 
from  the  standpoint  of  prophylaxis.  The  scales  from  these  desquama- 
tions are  certainly  less  infectious  than  those  of  the  primary  desquama- 
tion. It  is  the  belief  of  some  observers  that  they  are  not  capable  of 
conveving  the  disease.  There  seems  to  be  authentic  evidence,  however, 
that  even  in  tertiary  desquamations  the  scales  have  been  infective  and 
it  is  the  part  of  wisdom,  therefore,  to  regard  every  such  case  as  unsafe. 

Desquamation  is  not  the  only  factor  by  which  the  period  of  isolation 
is  to  be  determined.  Purulent  discharges  contain  the  infective  principle 
of  scarlet  fever.  No  child  who  is  still  suffering  from  otitis,  chronic 
pharyngitis,  or  a  purulent  discharge  of  any  kind  should  be  allowed  to 
mingle  with  others.  These  dangers  have  not  been  sufficiently  recog- 
nized and  as  a  result  the  disease  has  undoubtedly  been  communicated 
to  many  children.  In  many  cases  six  weeks  is  ample  quarantine  and  the 
patient  may  be  released  with  perfect  safety  to  others.  In  other  cases  he  is 
almost  as  dangerous  at  this  time  as  during  the  first  week  of  the  eruption. 
The  rule  for  quarantine  should  be  not  a  fixed  number  of  days  or  weeks, 
but  the  time  that  is  necessarv  for  the  disappearance  of  all  desquamation 
and  every  purulent  discharge.     The  question  of  infection  after  release 


510  IXFI'X'TIorS    DISh'ASES 

horn  (luanintiiR'  has  of  late  been  the  sul)jeet  of  some  (Hscussion  hi 
England,  and  an  attempt  has  been  made  to  prevent  more  fully  what 
they  call  "return  cases."  At  the  Monsall  Fever  Hospital  in  Man- 
chester, for  example,  the  f()llo\vin<;  method  has  been  adopted:  Certain 
wooden  pavilions  are  set  apart  as  convalescent  wards  for  scarlet  fever 
cases,  no  case  being  sent  into  these  wards  until  six  weeks  have  elapsed 
from  the  onset  of  the  fever.  Even  then  desquamation,  as  well  as  all 
pnrulent  discharges,  must  have  ceased.  The  convalescent  children  are 
encouraged  to  take  exercise  freely  iu  the  oj)en  air.  I  am  unable  to  say 
how  long  they  are  retained  in  these  wards,  but  the  statement  is  made 
that  since  this  system  has  been  in  operation  there  has  been  no  "return 
case,"  although  they  were  not  imcommon  before  that  time. 

The  cjuestion  of  isolating  mild  but  undoubted  cases  of  scarlet  fever 
is  fre(|uently  a  trying  one.  In  .some  of  these  des(juamation  is  very 
slight  and  there  is  no  purulent  discharge.  It  is  undonbtedly  a  fact  that 
the  (piarantine  can  be  raised  in  a  few  of  these  cases  in  less  than  six 
weeks.  Still  the  desquamation,  even  when  slight,  is  liable  to  persist  for 
a  greater  period  than  its  intensity  might  lead  one  to  expect,  and  mild 
cases  recpiirc  more  than  ordinary  precantion. 

Schools  and  public  a.ssemblages  are  active  agents  in  the  dissemination 
of  the  infectious  diseases.  One  means  by  which  schools  aid  in  the 
spread  of  scarlet  fever  is  through  the  clothing  of  children  who  may 
have  come  from  families  where  the  disease  exists.  No  better  incubator 
for  bacteria  could  l)e  provided  than  some  of  the  dark,  close,  warm 
school  closets  filled  with  damp  clothing.  The  advisability  of  closing 
schools  in  an  epidemic  of  scarlet  fever  must  be  settled  differently  in 
different  communities.  In  the  country  and  small  towns,  where  the 
children  will  be  separated  from  each  other  when  the  schools  are  closed, 
their  closure  may  be  an  important  measure  of  prevention.  Moreover, 
in  such  communities  people  are  known  to  each  other.  Illness  is  at  once 
known  and  contagion  can  be  guarded  against.  In  large  cities,  on  the 
other  hand,  the  conditions  are  quite  different,  particularly  in  the  crowded 
tenement  regions.  Here  the  children  cannot  and  will  not  be  confined 
to  their  homes,  but  will  mingle  with  each  other  all  day  long.  Closing 
of  the  schools  will  not  prevent  it.  The  daily  inspection  of  the  children 
in  city  schools  is  a  great  safeguard  against  the  spread  of  the  disease. 

It  is  unf(uestionably  a  fact  that  medical  men  through  carelessness 
have  sometimes  been  instrumental  in  carrying  scarlet  fever.  No  other 
disease  is  so  frecpiently  transmitted  through  the  agency  of  clothing. 
Sputa  coughed  out  during  examination  or  scales  adhering  to  the 
clothes  may  cause  the  disease  in  other  children  upon  whom  the  doctor 
may  be  in  attendance.  A  practitioner  should  never  visit  a  case  of 
scarlet  fever  or  diphtheria  without  a  gown.  Such  a  gown  should  be 
made  to  button  closely  about  the  neck  and  wrists,  and  should  l>e  long 
enough  to  reach  to  the  feet  and  have  a  hood  to  cover  the  head.  It 
should  be  put  on  before  entering  the  sick-room  and  should  be  hung  up 
in  the  bath-room  or  other  suitable  place  upon  leaving.  Upon  the  ter- 
mination of  the  case  the  gown  may  be  thoroughly  boiled  and  used  again. 


SCARLET   FEVER  511 

In  considerable  experience,  I  have  never  found  a  parent  or  child 
who  objected  to  it.  On  the  contrary,  it  inspires  confidence  in  the 
physician  and  removes  the  possibility  of  his  ever  being  charged  with 
bringing  the  disease  into  the  house  should  its  occurrence  in  one  of  his 
families  be  unexplainable.  The  hands  and  face  should  be  disinfected 
after  every  visit  to  a  scarlet  fever  patient.  The  same  is  true  of  the 
stethoscope,  which  should  be  used  for  all  physical  examinations  of  the 
chest.  The  tongue  depressor  or  other  instrument  used  about  the  throat 
should  not  be  taken  from  the  room.  The  doctor  himself  should  not 
carry  out  the  details  of  the  treatment  farther  than  is  strictlv  necessarv. 
It  is  difficult  for  him  to  do  so  without  danger  of  carrying  the  disease. 
It  can  only  be  avoided  by  more  thorough  disinfection  than  most  doctors 
are  willing  to  undergo.  In  few  diseases  is  the  importance  of  a  qualified 
nurse  greater  than  in  scarlet  fever.  One  should  be  secured  wherever 
it  is  possible.  Not  only  are  the  details  of  prevention  and  treatment 
carried  out  more  thoroughly  and  satisfactorily,  but  the  doctor  is  relieved 
of  many  duties  which  he  should  not  be  obliged  personally  to  perform. 

Sick-room. — A  room  for  the  patient  should  be  selected  which  can  be 
most  readily  isolated  and  will  at  the  same  time  be  convenient  and  habit- 
able. Six  weeks'  confinement  to  a  single  room  is  a  trving  ordeal,  and  isola- 
tion during  the  last  days  of  the  period  can  be  more  strictly  enforced  if 
the  room  is  cheerful  and  comfortable.  AMiile  a  room  at  the  top  of 
the  house  is  the  most  desirable,  another  should  be  selected  if  it  is 
nearer  to  a  bath-room.  The  passing  to  and  fro  to  the  bath-room  will 
frequentlv  undo  all  efforts  at  isolation,  not  to  speak  of  the  additional 
labor  involved.  All  unused  doors  should  be  sealed  with  strips  of 
paper  or  rubber  plaster.  The  floor  should  be  without  carpet  and 
if  the  boards  are  separated  by  wide  cracks  muslin  should  be  tacked 
down.  The  ease  of  preventing  the  spread  of  the  disease  is  greatly 
augmented  if  a  third  person  is  available.  To  this  person  is  assigned 
the  dutv  of  carr^•ing  the  food  and  various  articles  required  by  the 
nurse  and  of  taking  away  the  soiled  clothing  and  performing  the 
numerous  offices  outside  the  sick-room.  She  thus  comes  in  direct 
contact  neither  ^-ith  the  sick  nor  the  weH.  It  is  a  hardship  for  the 
mother  to  make  a  choice  between  the  invalid  and  the  other  chil- 
dren, particularly  if  they  be  smah,  but  the  necessity  of  her  doing  so 
is  urgent.  Such  toys  as  are  left  for  the  child's  amusement  should 
never  be  removed  from  the  room.  Hanging  dampened  sheets  before 
the  doors  is  of  some  practical  value.  It  is  not  to  be  supposed  that  they 
can  disinfect  the  air  or  destroy  the  germs,  but  they  do  prevent  currents 
of  air  when  the  doors  are  opened  and  are  a  constant  reminder  of  the 
necessity  of  care. 

The  preparation  of  one  room  for  a  sick-room  in  a  house  where  there 
are  children  is  a  wise  measure.  Such  a  room  is  not  infrequently  found 
in  modern  houses  and  should  be  more  common.  It  may  be  made  as 
cheerful  and  available  for  ordinary  use  as  any  other  room.  The  walls 
and  ceilings  should  be  painted  or  covered  with  tiles  or  washable  paper 
and  the  floor  polished  and  covered  ^-ith  rugs  instead  of  a  carpet.     The 


512  IXFECTIOrs   DISEASES 

liaiifiinjis  should  he  ca.^ily  rcinoval)lr  and  the  furniture  should  l»e  j)laiuly 
made  of  polished  wood  or  white  enamel.  A  room  thus  arranged  ean 
he  (luieklv  put  into  commission  a.s  a  siek-room  and  will  greatly  simplify 
the  question  of  prophylaxis. 

General  inunction  of  the  body  is  a  most  (>ffectivc  measure  both  of 
treatment  and  prophylaxis.  It  may  be  begun  as  soon  as  the  eruption 
has  appeared  and  should  be  continued  until  de.squamation  has  ceased. 
During  the  stage  of  eruption  before  the  stage  of  desquamation  has 
begun,  a  simple  l)land  oil  is  most  desirable.  Antiseptics  can  be  of  little 
avail  and  all  irritating  preparations  should  be  avoided.  Lanolin  is  one 
of  the  best  of  these,  or  a  mixture  of  equal  parts  of  lanolin  and  cold 
cream.  These  preparations,  however,  are  somewhat  expensive.  Vaselin, 
therefore,  mav  be  employed  in  their  stead,  and  is  no  doubt  the  most  com- 
mon preparation  used.  Some  of  the  cheaj)er  grades  of  yellow  vaselin  are 
irritating  to  delicate  skins.  When  itching  and  irritation  of  the  skin  is 
•rreat,  a  5  per  cent,  ointment  of  boric  acid  and  vaselin  is  sometimes 
ettective.  Sponging  with  a  solution  of  borax  and  water,  followed  by 
carbolized  vaselin,  will  also  give  temporary  relief.  Carbolized  vaselin, 
however,  should  not  be  used  over  large  areas.  In  scarlet  fever  we  do  not 
have  a  healthy  skin,  and  it  seems  quite  possible  that  absorption  might 
occur.  In  a  disease  in  which  the  kidneys  are  fretjuently  involved,  it 
is  unwise  to  run  any  risk  of  introducing  so  irritating  a  substance  as 
carbolic  acid. 

After  (les(iuamation  has  begun  the  objects  of  inunction  are  quite 
different.  The  procedure  becomes  then  a  matter  of  prevention  as  well 
as  treatment  and  the  most  important  object  is  to  soften  and  loosen  the 
scales,  thus  preventing  their  dissemination  with  the  resulting  danger  of 
spreading  the  infection.  It  seems  somewhat  doubtful  that  the  scales  can 
be  disinfected  bv  adding  disinfectants  to  the  oily  sul)stance  used  for 
inunction.  But  this  must  be  settled  at  some  future  time  by  the  bac- 
teriologist. The  general  fact  is  at  least  positively  settled  that  proper 
care  of  the  skin  during  the  state  of  descpiamation  is  one  of  the  most 
effective  means  of  limiting  the  spread  of  the  flisease,  and  also  without 
iloubt  of  shortening  the  time  of  desquamation.  Antiseptics  may  be 
added  to  the  ointment  or  oil  used  for  inunction.  The  boric  acid  oint- 
ment already  referred  to  is  one  of  the  best.  A  2  per  cent,  ichthyol 
ointment  has  its  advantages,  but  is  ol)jectionable  to  many  patients 
because  of  the  odor.  Carbolic  ointment  may  l)e  used  over  limited 
areas.  During  this  stage  the  inunction  may  be  preceded  by  a  bath  or 
sponging  with  water  at  a  temperature  of  90°  F.  The  water  may  be 
plain  or  it  may  contain  a  small  amount  of  salt  or  borax.  The  use  of 
an  antiseptic,  soap  is  advocated  by  many  practitioners,  resorcin  soap 
being,  perhaps,  the  most  conmionly  used. 

A  preparation  having  even  a  slight  odor  becomes  perceptible  when 
applied  to  the  whole  surface  of  the  body,  and  may  cause  loss  of  appe- 
tite. This  is  the  chief  objection  to  l3e  urged  against  the  animal  fats 
like  lam!)  fat,  mutton  tallow,  or  beef  suet.  The  bacon  rind  popular  in 
some  parts  of  the  country  has  the  same  objection  and  possesses  no 


SCARLET   FEVER  513 

advantages.  Lard  has  but  little  odor,  but  it  is  difficult  to  obtain  it  pure 
in  cities.  The  physician  should  always  make  sure  as  to  the  character 
of  the  preparation  used  for  inunction.  A  rancid  fat  in  a  severe  case 
of  scarlet  fever  may  cause  great  irritation  and  prolong  the  period  of 
desquamation. 

The  best  disinfecting  agents  for  house  use  are  bichloride  of  mercury 
and  carbolic  acid.  A  standard  solution  of  bichloride  of  the  strength  of 
1  :  1000  may  be  made  by  using  "antiseptic  tablets"  or  by  dissolving 

4  gm.  (1  dr.)  of  bichloride  and  30  gm.  (one  ounce)  of  common  salt  in 
4000  c.c.  (one  gallon)  of  water.    A  standard  solution  of  carbolic  acid  of 

5  per  cent,  strength  (1  to  20)  may  be  made  by  dissolving  180  gm. 
(six  ounces)  of  carbolic  acid  in  4000  c.c.  (one  gallon)  of  water.  For 
the  various  conditions  in  scarlet  fever  and  other  diseases  requiring 
disinfections,  these  solutions  may  be  used  as  follows:  For  the  hands 
and  person  the  carbolic  solution  in  one-half  or  one-third  strength.  For 
clothing,  towels,  and  bedding  the  carbolic  solution  in  full  strength  for 
one  hour,  after  which  they  should  be  boiled.  For  closets,  drains,  and 
sinks,  either  solution  in  full  strength.  All  discharges  from  the  mouth 
and  nose  should  be  received  in  glass  or  porcelain  vessels.  Either  solu- 
tion should  then  be  added  in  full  strength  and  at  least  twice  the  volume 
of  the  discharge.  After  standing  for  one  hour  the  whole  may  be  thrown 
into  the  closet.  For  sputa  cups,  full-strength  carbolic  solution  should  be 
used.  Certain  dishes  should  be  reserved  for  the  sole  use  of  the  patient. 
They  should  be  disinfected  with  full-strength  carbolic  solution  and  then 
boiled  and  rinsed.  The  remains  of  meals  should  be  burned.  When  the 
patient  has  recovered,  the  entire  body  should  be  bathed  and  the  hair 
washed  with  hot  water  and  soap.  He  should  then  be  dressed  in  clean 
clothes  (which  have  not  been  in  the  room  during  his  sickness)  and 
removed  from  the  room.  The  bodies  of  those  who  have  died  from 
scarlet  fever  or  other  contagious  disease  should  be  wrapped  in  cloths 
saturated  with  either  solution,  preferably  the  bichloride,  in  full  strength. 
All  the  antiseptics  named  in  strong  solution  are  more  or  less  irritating 
to  the  skin.  For  use  about  the  eyes  and  other  places  a  saturated 
solution  of  boric  acid  is  largely  used.  It  is  not  poisonous  or  irritating 
to  the  mucous  membranes. 

Prolonged  boiling  is  one  of  the  best  antiseptic  measures  at  our 
command.  Hence,  towels,  handkerchiefs,  and  all  articles  of  cloth- 
ing and  bedding  which  may  be  boiled  or  steamed  can  be  thus  ster- 
ilized. Handkerchiefs  and  towels  should  be  used  about  contagious 
cases  as  little  as  possible.  In  their  place  pieces  of  old  cloth  or 
squares  of  cheese-cloth  should  be  used,  and  these  may  then  be 
burned,  thus  avoiding  the  trouble  and  possible  danger  from  imper- 
fect disinfection.  If  they  cannot  be  at  once  burned,  they  should  be 
at  once  dropped  into  one  of  the  full-strength  solutions.  If  the  floor 
of  the  sick-room  be  bare,  it  should  be  wiped  daily  with  the  solution 
of  bichloride  in  full  strength.  If  the  carpet  is  covered  with  muslin,  this 
should  be  brushed  over  daily  with  the  same  solution. 

At  the  termination  of  such  diseases  as  scarlet  fever,  diphtheria,  and 
33 


514  INFECTIOUS  DISEASES 

smallpox,  all  toys  and  books  should  be  destroyed.  Books  are  partieu- 
larly  dan<i;erous,  for  they  cannot  be  adecjuately  disinfected.  The  room 
should  be  washed — floors,  walls,  and  ceiling — with  a  full-strength 
bichloride  solution,  and  the  furniture  should  be  wiped  with  the  same 
antise})tic.  Carpets,  upholstery,  hangings,  bedding,  and  mattresses 
should,  if  })ossil)le,  l)e  disinfected  with  steam.  When  this  is  impossible, 
they  should  be  wi])ed  thoroughly  with  cloths  danij)ened  in  the  bichloride 
solution  and  then  fumigated.  After  this  they  should  be  hung  for  tlays 
in  the  open  air  and  sunlight.  As  it  is  difhcult  to  certainly  disinfect 
articles  of  this  character  except  by  steam,  all  those  of  lesser  value  should 
be  sacrificed. 

Before  the  sick-room  is  again  occupied,  it  should  be  thoroughly  fumi- 
gated. Fumigation  with  sulphur,  as  it  is  ordinarily  done,  is  ineffective, 
owing  to  the  small  amount  of  sulphur  used  and  the  dryness  of  the  atmos- 
])here.  The  various  objects  in  the  room  should  be  dampened,  and  steam 
should  be  generated  in  it  if  possible.  Three  pounds  of  sulphur  are  neces- 
sary for  each  1000  cubic  feet  of  air  space,  with  eight  hours' exposure. 
The  sul})hur  is  best  used  in  the  form  of  fumigating  candles,  which  may 
be  found  in  every  drug-store.  It  is  best  to  place  each  candle  in  a  shallow 
ba~sin  of  water  to  avoid  danger  of  fire.  The  room  should  be  sealed  by 
pasting  strips  of  paper  or  rubber  plaster  over  all  cracks  and  key-holes. 
It  should  be  kept  closed  for  at  least  eight  hours  after  the  sulphur  is 
lighted  and  thoroughly  aired  before  it  is  again  occupied. 

Formaldehyde  gas  is  superior  to  sulphur  for  room  fumigating.  It  is 
commonly  generated  from  formalin,  which  is  a  solution  of  formaldehyde 
in  water.  For  this  purpose  several  generators  have  been  devised.  Not 
less  than  175  c.c.  (six  ounces)  of  formalin  should  be  used  for  each  1000 
cubic  feet  of  space,  and  infected  articles  should  be  ex-posed  to  its  action 
for  not  less  than  four  hours.  Formaldehyde  burns  easily,  and  may  be 
set  on  fire  by  an  open  flame.  It  is  an  excellent  deodorizer  as  well  as 
disinfectant.  The  necessary  apparatus  is  now  in  the  hands  of  most 
boards  of  health,  and  a  small  generator  sufficient  for  the  disinfection 
of  rooms  of  ordinary  size  can  be  obtained  at  not  large  expense.  In 
the  absence  of  a  generator  the  formalin  may  be  evaporated  from  sheets 
suspended  from  the  ceiling.  It  is  very  irritating  and  must  be  handled 
with  care. 

It  must  be  remembered  that  in  scarlet  fever  we  have  not  the  sure 
basis  of  knowledge  which  we  possess  in  diphtheria.  Until  a  specific 
germ  has  been  discovered  and  its  life  history  studied,  we  must  rely  on 
clinical  evidence  alone.  We  must,  therefore,  expect  to  find  differences 
of  opinion  on  almost  every  detail  of  pathogenesis,  prophylaxis,  and 
treatment. 

Treatment. — Scarlet  fever  is  still  a  disease  over  which  we  have  but 
little  direct  control.  Many  .specifics  have  been  proposed,  tried,  and 
found  wanting.  Mucli  may  be  done  to  avert  complications  and  render 
them  less  serious  when  they  occur,  and  many  lives  may  be  saved  by 
judicious  management.  Mild  cases  require  little  or  no  medication; 
they  usually  receive  too  much.    The  disease  is  self-limiting  and  while 


SCARLET  FEVER  5I5 

it  is  running  a  normal  course  more  harm  than  good  will  result  from 
vigorous  treatment.  There  are  times,  on  the  other  hand,  when  treat- 
ment of  the  most  vigorous  nature  is  necessary  to  save  the  life  of  the 
child.  The  physician  should  see  that  the  patient  is  not  kept  too  warm. 
Fear  of  cold  and  dread  of  water  in  the  eruptive  diseases  must  constantly 
be  combated.  It  is  not  necessary,  but  rather  harmful,  to  sweat  the 
patient  to  "bring  out  the  rash."  The  popular  fear  of  bathing  in  the 
eruptive  fevers  has  no  rational  foundation. 

The  patient  should  be  kept  in  bed  for  at  least  three  weeks.  In  com- 
plicated and  prolonged  cases  the  rule  should  be  that  the  child  should 
not  be  allowed  to  leave  the  bed  for  at  least  a  week  after  the  fever  has 
subsided.  It  is  exertion  and  chilling  of  the  body  which  render  late 
complications  of  mild  cases  so  common.  It  is  the  best  rule,  therefore, 
to  keep  every  child  ill  with  scarlet  fever  confined  to  the  bed  for  twenty 
days,  even  if  the  attack  be  very  mild.  Quiet  in  bed  and  a  liquid  diet 
will  do  more  to  prevent  the  late  complications  than  any  other  means 
at  our  command.  If  the  rule  is  laid  down  at  once  that  the  patient  is  to 
remain  in  bed  for  three  weeks  it  can  always  be  carried  out.  Patients 
will  usually  accept  the  inevitable  with  but  little  objection,  but  will 
become  restless  under  uncertainty  or  half-hearted  methods. 

Milk  is  the  best  diet  for  scarlet  fever  patients.  It  may  be  given 
peptonized  or  plain.  If  milk  is  disliked  by  the  patient,  kumyss,  zoo- 
lak,  buttermilk,  or  junket  may  perhaps  be  substituted.  If  these 
preparations  are  not  taken  well,  gruels  or  foods  made  of  rice,  arrow- 
root, cornstarch,  farina,  barley,  or  wheat  flour  may  be  available.  Ani- 
mal broths  may  be  given  sparingly  to  form  a  variety.  Barley-water 
flavored  with  mutton  or  chicken-broth  is  an  excellent  substitute  if  milk 
becomes  too  irksome.  Cocoa  or  chocolate  may  also  be  used  to  cover 
the  taste  of  milk.  It  may  be  given  two  or  three  times  a  day  with  hot 
milk.  Plain  vanilla  ice-cream  may  be  given  in  small  amounts  when 
the  throat  is  dry  and  sore.  Milk  should  be  used  exclusively  if  possible 
during  the  first  two  weeks  and  should  form  a  large  part  of  the  diet 
during  the  subsequent  four  weeks.  Such  a  diet  with  rest  in  bed  will 
do  much  to  prevent  renal  complications.  Water  should  be  given  freely 
during  the  whole  course  of  the  disease.  It  aids  in  eliminating  waste 
products  from  the  body  and  perhaps  the  scarlatinal  poison,  and  thus 
diminishes  renal  irritation.  If  signs  of  nephritis  appear,  all  other  food 
should  be  at  once  stopped  and  the  patient  should  be  placed  again  on 
a  milk  diet  and  water  should  be  given  freely.  Nitrogenous  food  should 
be  used  sparingly  for  two  months  and  meat  should  be  wholly  eliminated 
from  the  diet  for  that  length  of  time.  As  the  patient  becomes  con- 
valescent the  diet  may  be  increased  by  the  addition  of  milk-toast,  junket, 
plain  rice-pudding,  cornstarch,  custards,  crackers,  cereals,  animal 
jellies,  baked  apples,  and  stewed  fruits.  In  the  later  weeks  eggs,  oysters, 
fish,  and  chicken  may  be  given. 

The  initial  vomiting  usually  requires  no  treatment,  but  the  bowels 
should  be  acted  upon  mildly  by  small,  repeated  doses  of  calomel.  Later 
they  should  be  kept  acting,  if  possible,  by  means  of  enemata  rather  than 


516  INFECTIOUS  DISEASES 

by  the  use  of  cathartic  drugs.  If  the  vomiting  is  persistent,  food  should 
be  withheld  for  ten  or  twelve  hours  and  iiot  water  or  cracked  ice  should 
be  given. 

While  the  eruption  is  developing  and  is  at  its  height  the  itching  and 
burning  of  the  skin  are  sometimes  very  distressing.  These  may  be  miti- 
gated l)y  the  use  of  a  weak  wash  of  carbolic  acid  and  borax  or  by  the 
use  of  carbolized  vaseHn.  In  some  cases  relief  is  obtained  by  sponging 
with  a  solution  of  bicarbonate  of  soda  in  water  (a  level  teaspoonful  to 
a  fjuart),  followed  by  anointing  with  cold  cream.  In  other  cases 
simj)le  talcum  powder  gives  more  relief.  Bathing  the  surface  with 
warm  water  followed  by  anointing  with  plain  or  carbolic  vaselin  or 
some  bland  ointment  should  be  begun  as  soon  as  the  first  signs  of 
desquamation  appear  and  should  be  continued  throughout  the  course 
of  the  disease.  This  daily  rubbing  of  the  surface  with  oil  is  a  most 
important  measure  of  treatment  and  should  never  be  omitted.  As  to 
the  oily  substance  used,  my  own  preference  is  for  cold  cream.  When 
well  made,  it  is  never  irritating  and  does  not  remain  on  the  skin  or  soil 
the  clothing  as  do  many  oils.  White  va.selin  and  pure  lard  are,  however, 
largely  used  and  are  less  expensive  than  cold  cream.  Other  details  of 
inunctions  have  already  been  given. 

In  mild  cases  stimulants  are  not  required  and  are  rarely  necessary 
in  cases  of  ordinary  severity.  In  severe  cases  they  are  frequently  rec|uired 
for  a  few  days  and  in  some  instances  must  be  used  persistently  and 
freely.  Alcoholic  stimulants  are  the  first  to  be  selected.  They  are 
required  in  all  tlie  septic  cases  as  well  as  those  of  the  malignant  type. 
As  in  other  conditions,  digitalis  is  indicated  when  the  pulse  becomes 
soft  and  weak  and  of  low  tension.  Holt  gives  one  minim  of  the  fluid 
extract  four  times  a  day  at  five  years.  Owing  to  the  tendency  to  renal 
and  cardiac  complications,  digitalis  is  a  drug  of  especial  value  in  scarlet 
fever.  Strychnine  is  also  of  value  in  septic  cases  with  prostration.  At 
five  years  of  age  0.00032  gm.  (yg^o"  S^-)  "^^J  ^^  given. 

In  ordinary  cases  antipyretic  treatment  is  not  necessary,  but  in  other 
cases  the  temperature  may  recjuire  attention  from  the  outset.  It  should 
not  be  forgotten  that  a  high  temperature  is  normal  to  scarlet  fever.  It 
may  be  allowed  to  run,  therefore,  without  interference,  to  a  somewhat 
higher  j)oint  than  in  most  other  flisea^ses.  H^'jjerpyrexia  or  a  temperature 
continuously  above  104°  F.  demands  treatment.  It  is  best  reduced  by 
means  of  the  cold  bath ;  but  this  for  obvious  reasons  is  less  practical  in 
private  than  in  hospital  j^ractice.  The  cold  ])ack  or  cold  sponging  is 
more  available.  An  effective  methorl  of  applying  cold  adopted  at  the 
Willard  Parker  Hospital  is  thus  described  by  Northrup:  "The  tendency 
in  all  cooling  processes  is  for  the  feet  to  become  cold.  To  obviate  this 
the  patient  is  placed  upon  l)lankets,  but  the  legs,  feet,  arms,  and  hands 
are  wrapped  in  warm,  dry  blankets  and  hot  bottles  are  enclosed  in  the 
wrappings.  An  ice-bag  is  applied  to  the  head.  The  face  and  head  are 
freely  sponged  in  warm  water  and  alcohol,  evaporation  being  hastened 
by  fanning  so  long  as  it  cools  the  patient,  clears  the  cerebrum,  gives 
force  and  improved  rh}^hm  to  the  heart,  and  leaves  the  patient  to  a 


SCARLET  FEVER  517 

quiet  sleep."  Great  caution  should  be  exercised  in  the  use  of  anti- 
pyretic drugs.  The  coal-tar  antipyretics  are  capable  of  doing  much 
harm  if  injudiciously  administered.  Tepid  sponging  with  ice  to  the 
head  is  usually  effective  in  mitigating  the  less  pronounced  nervous 
symptoms.  Opiates  are  rarely  to  be  advised.  The  coal-tar  products 
are  not  to  be  used  as  antip^Tetics,  but  phenacetin  in  small  doses  is 
admissible  when  there  is  extreme  restlessness  and  the  child  is  losing 
strength  from  sleeplessness.  For  the  convulsions  which  occur  in  rare 
instances  in  septic  cases,  warm  baths  and  chloral  administered  by  the 
rectum  0.324  gm.  (5  gr.)  at  five  years  should  be  employed. 

Burning;  and  soreness  of  the  throat  during  the  first  few  davs  mav  be 
mitigated  bv  giving-  cool  water  or  bits  of  ice.  In  the  simpler  forms  of 
pharyngitis,  hot  drinks  may  be  given  or  irrigation  of  the  back  of  the 
throat  with  hot  saline  or  boric  acid  solutions,  about  4  gm.  to  475  c.c. 
(one  drachm  to  a  pint)  may  be  employed.  Chlorate  of  potassium 
should  be  avoided.  Its  beneficial  effects  are  doubtful  and  its  known 
irritating  effect  upon  the  kidneys  contraindicates  its  use.  Nasal  irriga- 
tion should  be  avoided  unless  clearly  indicated.  Jackson,  of  the  Boston 
City  Hospital,  has  seen  less  otitis  when  it  has  not  been  generally  em- 
ployed. Irrigation  is  indicated  by  a  purulent  nasal  discharge  or  obstruc- 
tion of  the  nasopharynx.  ]\Iore  harm  than  good  may  residt  from  over- 
zealous  attempts  at  local  treatment  of  the  throat  and  nose.  Peroxide 
of  hydrogen  is,  in  my  opinion,  an  unsafe  remedy  in  such  conditions. 
It  is  an  irritant  even  when  rendered  alkaline,  and  it  has  the  power 
to  prolong  indefinitely  the  presence  of  pseudomembrane.  The  most 
successful  treatment  consists  not  in  the  use  of  active  and  poisonous 
antiseptics,  but  of  mild  and  cleansing  washes  freely  and  frequently 
applied.  The  error  should  not  be  made,  on  the  other  hand,  of  failing 
to  irrigate  the  nasal  passages  when  seriously  obstructed  either  by  a 
purulent  or  by  a  thick,  tenacious  discharge.  It  is  especially  essential  if 
adenitis  be  present  or  is  increasing.  The  solutions  used  for  this  purpose 
should  always  be  warm. 

Adenitis  can  only  be  controlled  by  checking  the  septic  process  in 
the  throat.  The  application  of  hot  oil  or  the  hot-water  bag  is  sooth- 
ing to  some  patients,  but  the  use  of  cold  is  preferable  in  most  cases. 
Small  ice-bags  applied  to  either  side  of  the  throat  usually  give  comfort 
to  the  patient  and  have  some  controlling  effect  upon  the  swelling.  A 
long,  thin  ice-bag  tied  by  a  string  in  the  centre  to  form  two  sections  is 
more  easily  kept  in  place  than  are  two  smaller  ones.  Poultices  should 
be  applied  for  short  intervals  only.  Their  continuous  use  renders  the 
parts  sodden,  favors  suppuration,' and  after  a  time  increases  the  pain. 
An  ointment  of  ichthyol  and  camphor  is  a  favorite  mode  of  treatment 
with  some  practitioners;  4  gm.  (1  dr.)  of  ichthyol  and  0.65  gm. 
(10  gr.)  of  powdered  camphor  may  be  used  to  31  gm.  (1  oz.)  of 
ointment.    Suppuration  should  be  treated  by  free  and  early  incision. 

Otitis  requires  the  treatment  demanded  by  the  disease  in  other 
conditions.  Early  puncture  of  the  drum  membrane  removes  a  part 
of  the  danger  of  extension  to  the  mastoid  ceils.    The  joint  affections  of 


518  INFECTIOrS  DISEASES 

the  ordinary  type  require  hut  little  treatment  aside  from  rest  and  pro- 
teetion.  The  joints  should  he  wrapped  in  ahsorhent  eotton  or  han(lai>;(>(l 
with  flannel.  If  the  sleep  is  hroken  l)y  pain  a  mild  o})iate  for  one  or  two 
nights  is  admissihle. 

Nephritis  should  receive  promj)t  and  very  careful  treatment.  Frequent 
examinations  of  the  urine  should  he  made  and  treatment  should  hegin 
promptly  upon  the  first  appearance  of  alhumin  after  the  second  week. 
It  should  he  rememhered  that  it  is  an  es})ecially  acute  nephritis  which 
is  present  and  that  all  irritating  drugs  should  he  carefully  avoided. 
The  saline  diuretics  like  citrate  and  acetate  of  potash  are  especially 
helpful.  Digitalis  is  of  peculiar  value  in  this  form  of  disease.  A 
freshly  prepared  infusion  is  the  hest  preparation  for  such  use  and 
may  be  given  at  the  outset  in  doses  of  4  c.c.  (1  dr.)  every  four 
hours  to  a  child  of  five  years.  It  may  he  comhined  with  a  saline 
diuretic.  The  free  administration  of  water  throughout  the  course  of 
the  disease  is  important  as  a  preventive  measure  as  well  as  a  measiu'e 
of  treatment.  Lithia  water  is,  perhaps,  more  helpful  than  plain  water. 
Flushing  the  howel  with  hot  water  after  the  method  of  Kemp  with  a 
douhle-flow  rectal  tuhe,  Is  another  measure  of  especial  value.  A  little 
alhumin  may  appear  for  a  few  days  without  symptoms  of  any  kind 
and  may  soon  disappear  without  leading  to  serious  consequences.  It 
should,  however,  always  be  heeded  as  a  danger  signal.  A  milk  diet 
should  be  given  and  the  patient  should  he  carefully  watched. 

The  serum  treatment  of  scarlet  fever  has  received  very  careful  study 
from  some  of  the  ablest  observers.  It  can  only  be  said  that  it  has 
proved  disappointing.  The  last  reports  at  the  time  of  writing  are 
distinctly  unfavorable.  Baginsky,  who  has  been  a  champion  of  the 
idea  that  scarlet  fever  is  the  result  of  streptococcus  infection,  has  very 
recently  reported  his  results  with  the  serum  treatment.  He  first  used 
the  Marmorek  antistreptococcus  serum  and  later  the  Aronson  serum. 
He  reports  a  series  of  ()2  eases  treated  with  the  latter.  The  mortality 
among  these  cases  was  a  little  lower  than  that  among  a  series  of  cases 
treated  without  it,  but  the  difference  was  so  small  as  to  ofl^er  but  little 
ground  for  encouragement.  Neither  the  general  condition  nor  any 
particular  symptom  was  materially  changed  for  the  better.  Because  of 
its  apparent  unfavorable  action  in  4  cases  the  use  of  the  serum  was  not 
continued.  Escherich  has  also  reported  results  with  another  form  of 
serum,  but  without  any  material  improvement  in  the  mortalitv  rates. 
When  given  early  and  in  large  (juantities  there  was  some  apparent 
beneficial  effect.  From  all  the  evidence  available  the  serum  treatment 
is  not  to  be  commended. 

As  emaciation  and  anemia  are  frequent  results  of  scarlet  fever,  active 
tonic  treatment  should  be  instituted  during  convalescence,  the  chief 
reliance  being  placed  upon  iron.  Basham's  mixture  is  especially 
indicated.  The  patient  should  be  carefully  protected  from  cold,  for 
exposure  not  infrequently  seems  to  precipitate  nephritis  long  after  the 
period  of  its  usual  occurrence.  The  urine  should  be  examined  at 
intervals  after  the  child  has  fully  recovered  and  the  tom'c  treatment 
should  be  continued  for  a  consi(leral)le  time  if  the  anemia  persists. 


CHAPTER    XX. 

:\IEASLES— RUBELLA— FOURTH  DISEASE— ERYTHE:\L\ 
INFECTIOSOI. 

MEASLES. 

By  FLOYD  M.  CRAXDALL,  M.D. 

Measles,  Rubeola,  or  Morbilli,  is  an  acute,  infectious,  and  contagious 
disease  occurring  most  commonly  in  children,  Tj-pical  cases  present 
the  following  features:  After  an  incubation  of  twelve  days  there  is  a 
gradual  invasion  marked  by  fever  with  dry,  metallic,  teasing  cough, 
coryza,  and  suffusion  of  the  eyes,  followed  on  the  fourth  day  by  a  coarse, 
maculopapular  eruption  which  appears  first  on  the  temples,  neck,  and 
sides  of  the  face.  The  eruption  spreads  slowly  until  the  body  is  covered, 
and  appears  last  on  the  hands  and  feet.  It  continues  for  about  five  davs 
and  slowly  fades  away  in  the  order  in  which  it  came.  It  is  followed  by 
a  bran-like  desquamation,  which  usually  continues  not  longer  than  seven 
or  eight  days.  INIeasles  is  contagious  from  the  first  symptoms  of  coryza, 
a  fact  which  partially  explains  its  widespread  occurrence.  Susceptibility 
to  measles  is  greater  than  to  most  other  diseases  and  very  few  escape  it. 

Etiology.  Exciting  Cause. — IMeasles  is  the  most  contagious  of  the 
infectious  diseases  except  smallpox,  but  the  infective  principle  soon 
disappears  from  rooms  and  clothing.  No  specific  micro-organism, 
however,  has  been  discovered,  ^^'hatever  the  exciting  cause  may  be, 
it  is  evident  that  it  is  very  diffusible  and  of  low  vitality. 

Predisposing  Causes. — Predisposition  to  measles  is  more  universal 
than  to  any  other  disease  except  possibly  smallpox  and  influenza. 
Every  child  over  one  year  of  age  who  has  not  already  had  it  may  be 
expected  to  contract  it  upon  exposure.  Adults  who  have  not  had  the 
disease  are  also  more  susceptible  to  it  than  to  the  other  infectious 
diseases.  Under  one  year  measles  is  rare  and  under  six  months  is 
extremely  infrequent.  I  have  seen  an  infant  of  six  months  who  was 
kept  in  a  room  with  a  measles  patient  during  the  whole  course  of  the 
disease  without  contracting  it.  Cases  have  been  reported,  however,  of 
newborn  infants  contracting  the  disease  from  their  mothers  who  were 
suffering  from  it  at  the  time  of  birth.  I  have  recently  seen  a  t^-pical 
case  in  an  infant  of  five  months.  The  comparative  immunity  of  adults 
is  explained  largely  by  the  fact  that  few  escape  infection  during  child- 
hood. In  localities  where  the  disease  has  not  pre^'ailed  for  years  it  has 
been  noted  that  all  ages  and  conditions  suffer.  Sex  is  not  a  predisposing 
factor  and  has  no  relation  whatever  to  the  occurrence  of  the  disease. 

(519) 


520  INFECTIOUS  DISEASES 

Neither  is  social  condition  a  predisposing  factor,  for  children  living  in 
hygienic  surroundings  are  apparently  as  susceptible  as  those  living  in 
tenement  districts. 

Measles  is  endemic  in  all  cities  and  large  towns,  hut  at  intervals 
becomes  epidemic  and  spreads  over  a  wide  area  before  it  expends  itself. 
These  epidemics  are  frequently  widespread  and  affect  large  numbers  of 
children.  There  is  no  law  of  periodicity  governing  epidemics  of  measles. 
Tiiey  are  more  common  (hiring  tlu>  colder  montlis  of  the  year  and  are 
rare  diu'lng  the  summer.  In  New  York  City  the  disease  is  most  common 
during  the  late  winter  and  early  spring  an(l  is  least  frequent  in  the  early 
autunni.  Notwitiistanding  the  fact  of  the  great  susceptibility  shown 
by  most  children  to  measles,  some  are  occasionally  seen  who  appear 
to  be  immune.  They  do  not  contract  the  disease  afti-r  prolonged  close 
exposure.     I  have  recently  seen  a  marked  case  of  this  character. 

Sources  of  Infection. — Aleasles  may  be  transmitted  by  direct  contact, 
and,  hence,  is  a  true  contagious  disease.  The  area  of  contagion  is  large 
and  very  brief  ex])()sure  is  sufficient.  It  may  be  conveyed  a  considerable 
distance  through  the  open  air.  In  an  enclosed  room  it  may  be  con- 
tracted by  a  child  fifteen  or  twenty  feet  from  the  patient.  It  seems 
possible  that  the  contagium  may  be  conveyed  by  the  bi-eath,  but  it  is 
certain  that  it  resides  in  the  sputa  and  the  discharges  from  the  nose 
and  eyes.  It  has  been  conveyed  to  monkeys  l)y  inoculating  their  throats 
with  mucus  obtained  from  the  throats  of  measles  patients.  It  is  prob- 
able also  that  it  resides  in  the  desc{uamation  scales,  but  is  far  less  potent 
than  is  the  poison  carried  by  the  des(|uamation  of  scarlet  fever.  The 
disease  may  be  conveyed  by  clothing  or  bedding,  or  it  may  be  contracted 
by  a  susceptil)le  person  entering  a  room  wiiich  has  recently  been  left 
by  a  measles  patient.  At  the  Randall's  Island  Hospital  measles  was 
conveyed  by  a  kitten  which  escaped  from  a  measles  ward  and  was 
allowed  to  lie  in  the  bed  of  several  children  in  another  ward.  Such 
intermediate  contagion,  however,  is  very  rare  in  measles.  It  is  doubt- 
ful whetiier  it  is  ever  conveyed  from  one  child  to  another  by  a  person 
who  has  been  only  for  a  short  time  in  contact  with  a  patient.  It  seems 
entirely  possible  that  a  nurse  who  goes  directly  from  a  measles  })atient 
to  a  healthy  child  without  disinfection  might  transmit  the  disease  if  she 
comes  also  iti  close  contact  with  it.  I  am  not,  however,  p(M-sonally 
awai'c  of  such  a  case.  The  case  of  the  cat  is  the  only  one  of  undoubted 
intermediate  infection  which  has  come  under  my  own  ol)servation. 

Period  of  Incubation. — The  period  of  incubation  ranges  from  nine  to 
twenty-one  days.  It  was  found  liy  Holt  to  be  between  eleven  and 
fourteen  days  in  66  per  cent,  of  144  carefully  observed  cases.  In  but 
one  case  was  it  less  than  a  week.  From  all  the  evidence  availal)le  I  should 
give  twelve  days  as  the  most  common  period  of  incubation.  The  average 
period  differs  somewhat  in  different  epidemics,  being  a  little  shorter 
some  years  than  others. 

Period  of  Infection. — Measles  is  contagious  from  the  first  appearance 
of  the  catarrhal  symptoms.  Well-authenticated  cases  are  recorded  in 
which  it  was  transmitted  four  days  before  the  rash  appeared.     It  is 


MEASLES  521 

believed  to  be  most  contagious  when  the  fever  and  catarrhal  symptoms 
are  at  the  highest.  The  contagiousness  diminishes  as  the  active  symp- 
toms subside  and  is  slight  during  the  stage  of  desquamation.  Except 
in  complicated  cases  in  which  the  catarrhal  symptoms  are  prolonged 
or  purulent  discharges  are  present,  the  contagious  period  is  not,  at  the 
longest,  over  twenty-eight  days.  In  most  cases  it  is  passed  at  the  end 
of  twenty-one  days.  It  is  proper  to  add  that  there  are  still  differences 
of  opinion  regarding  the  period  of  greatest  contagiousness,  the  belief  of 
some  being  that  it  is  actively  contagious  during  desquamation. 

Pathology. — The  lesions  of  measles  are  confined  to  the  skin  and  the 
nuicous  membranes  of  the  conjunctiva,  nose,  pharynx,  larynx,  and  the 
larger  bronchial  tubes.  The  changes  of  the  mucous  membranes  are  as 
much  a  part  of  the  disease  as  are  those  of  the  skin.  The  morbid  changes 
of  the  skin  are  those  of  hyperemia.  On  the  mucous  membranes  they 
are  those  of  acute  catarrh.  Pseudomembranous  inflammation  may 
occur  in  complicated  cases.  The  complications  are  apparently  due  to 
other  micro-organisms  than  the  specific  germ  of  measles.  Complicated 
measles  is,  therefore,  a  mixed  infection,  the  most  common  compli- 
cating germ  being  the  staphylococcus.  The  streptococcus  is,  however, 
often  present  and,  as  a  rule,  causes  more  serious  lesions  than  does 
the  staphylococcus.  The  pneumococcus  is  also  frequently  found.  As 
pneumococci  and  streptococci  are  frequently  present  in  hospital  wards, 
measles  occurring  in  hospitals  is  very  prone  to  be  complicated.  In  an 
epidemic  in  the  Infants'  Hospital,  Randall's  Island,  the  first  12  cases 
which  developed  were  complicated  by  pneumonia.  In  children's 
hospitals  this  tendency  to  complication  by  extraneous  germs  renders 
measles  one  of  the  most  dreaded  of  diseases,  the  death  rate  often  being 
very  high. 

Clinical  Types. — Measles,  as  a  rule,  presents  less  variation  from  the 
classical  type  than  does  scarlet  fever  and  most  of  the  other  infectious 
diseases.  Very  mild  cases  sometimes  occur,  but  they  are  less  common 
than  very  mild  cases  of  scarlet  fever,  while,  on  the  other  hand,  malignant 
cases  are  also  less  common.  Measles  is  also  fairly  constant  in  its  duration 
and  the  various  stages  are  well  defined.  Although  the  type  of  disease 
which  I  have  designated  as  the  ordinary  type  is  most  common,  measles 
is  capable  of  occurring  in  very  irregular  and  atypical  forms.  Such 
irregular  types  occur  most  commonly  in  children  under  three  years. 
In  most  epidemics  a  larger  proportion  of  measles  cases  will  run  a  regular 
course  than  will  a  similar  number  of  cases  of  scarlet  fever,  but  in  some 
epidemics  unusual  types  may  be  repeated  again  and  again.  Reports 
of  certain  epidemics,  therefore,  not  infrequently  show  a  far  greater 
number  of  complicated  or  irregular  cases  than  the  averages  based  on 
the  experience  of  several  years.  Thus,  in  an  epidemic  of  423  cases 
occurring  in  Canada,  as  reported  by  C.  J.  Edgar,  over  200  were  of 
hemorrhagic  form  and  103  were  classed  as  malignant. 

Ordinary  Type. — The  onset  of  measles  is  usually  gradual  and  is 
characterized  by  feverishness,  sneezing,  coryza,  suffusion  of  the  eyes, 
photophobia,  and  a  general   feeling  of  illness.     Occasionally  a  chill 


r,22  INFECTIOUS  DISEASES 

followod  by  a  high  tcinpcraturc  is  thr  initial  syni})t()in.  Within  twenty- 
four  hoiirs'aftcr  tiie  advent  of  the  first  symptoms  a  characteristic,  liard, 
dry  coiifih  appears  and  the  child  shows  all  the  signs  of  a  catarrhal  cold. 
The  coryza,  however,  is  more  marked  than  is  that  of  an  ordinary  cold 
and  the'couo-h  has  a  peculiar  m(>tallic  character.  The  fever  increases 
a-s  the  eruptii)n  appears  and  frecpiently  is  at  its  height  on  the  first  (lay 
of  the  eruption.  A  few  spots  commonly  appear  on  the  afternoon  of  the 
fourth  day,  but  may  sometimes  be  seen  as  early  as  the  second  day  and 
in  rare  cases  as  late  as  the  fifth  or  sixth  day.  The  early  appearance  of 
the  eruption  is  more  common  in  young  children.  There  are  no  char- 
acteristic constitutional  symptoms  upon  which  a  diagnosis  can  be 
made. 

The  temperature  on  the  first  day  is  usually  not  above  102°  F.  but 
will  occasionally  be  found  at  103°  or  104°  F!  The  fever  do(>s  not,  as 
a  rul(\  range  as  high  in  measles  as  in  scark>t  fever.  After  a  sharp  rise 
on  the  first  day,  the  temperature  not  infn^cjuently  falls  on  the  second 
and  third  days,  but  increases  as  the  eruption  begins  to  appear  and 
reaches  its  height  on  the  second  day  of  the  eruption.  It  then  falls 
gradually  day  by  day  and  becomes  normal  between  the  seventh  and 
ninth  (hiv  of  the  disease.  Not  infrequently  there  is  a  sudden  fall  on 
the  sixth  or  seventh  day,  forming  almost  a  crisis.  The  diminution  of 
the  fever  on  the  second  or  third  clay  is  sometimes  so  decided  as  to  lead 
to  error  in  diagnosis.  The  possibility  of  such  a  fall  should  not  be 
forgotten,  particularly  should  the  catarrhal  symptoms  and  cough 
contimie  undiminished.  The  fever  and  constitutional  symptoms  are 
usually  at  their  height  when  the  eruption  has  reached  its  fullest  develop- 
ment, on  the  fourth  or  fifth  day  of  the  disease. 

The  eruption,  as  already  stated,  more  commonly  appears  on  the 
fourth  (lav.  It  is  first  seen  on  the  temples  and  sides  of  the  face  or  on 
the  neck  and  behind  the  cars.  At  first  it  generally  consists  of  small 
red  spots  having  no  strictly  characteristic  appearance.  They  rapidly 
increase  in  size  and  form  small  macules  or  very  slightly  elevated  papules 
on  a  slightly  reddened  base  with  normal  skin  between.  They  are 
crescentic  or  circular  in  shape,  and,  being  hyperemic  in  character,  dis- 
appear on  pressure.  The  eruption  as  it  develops  l)ecomes  confluent  in 
places,  particularly  on  the  face,  where  it  assumes  a  blotched  appearance. 
The  eruption  usually  reaches  its  height  at  its  first  site  of  appearance 
at  the  end  of  thirty-six  hours;  it  remains  stationary  for  about  two  days 
and  then  rapidly  fades  away.  It  extends  ov(>r  the  body  somewhat 
slowly,  appearing  on  the  trunk  and  limbs  on  the  second  day.  The  wrists 
and  backs  of  the  hands  are  commonly  the  last  to  be  involved.  When 
at  its  height  in  these  places,  the  rash  has  sometimes  partially  faded  on 
the  face  and  neck.  The  spread  of  the  eruption  is  sometimes  extremely 
rapid,  the  whole  body  being  covered  in  a  few  hours,  l)ut  this  is  rare. 
l)es(|uamation  begins  as  soon  as  the  eruption  has  faded,  and  follows  the 
order  of  its  appearance.  It  rarely  continues  more  than  ten  days  in  any 
given  area  and  may  be  of  much  shorter  duration.  It  is  most  intense 
where  the  eruption  has  been  most  intense.     It  occurs  in  branny  scales 


PLATE  XVI. 


Fig.  1. 


Fig.  2. 


The  Pathognomonic  Sign  of  Measles  (Kophk's  Spots). 

Fig.  1. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing  the  isolated 
rose-red  spot,  with  the  minute  bluish- white  centre,  on  the  normally  colored  mucous  membrane. 

Fig.  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and  lips;  patches 
of  pale  pink  interspersed  among  rose-red  patches,  the  latter  showing  numerous  pale  bluish-white  spots. 

YiG.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles  spots  completely 
coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The  exanthema  on  the  skin 
is  at  this  time  generally  fully  developed. 

Fig.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal  in  hue. 
Minute  yellow  points  are  surrounded  by  a  red  area.     Always  discrete. 


MEASLES  523 

quite  unlike  the  lamellar  desquamation  of  scarlet  fever.  It  is  often  so 
slight  as  to  be  completely  overlooked,  particularly  when  inunctions  of 
the  skin  have  been  carefully  used.  Desquamation  is  usually  completed 
within  twenty  days  after  the  onset  of  the  disease. 

A  few  years  ago  a  symptom  was  described  by  Koplik,  of  New  York, 
which  has  been  accepted  as  a  valuable  aid  in  the  early  diagnosis  of 
measles.  This  symptom  consists  in  the  appearance  of  a  certain  char- 
acteristic eruption  on  the  inside  of  the  cheeks  and  lips.  On  the  first  day 
of  the  invasion  the  examination  of  the  buccal  mucous  membrane  in  a 
good  light  will  reveal  a  scattered  eruption  consisting  of  small,  irregular 
spots  of  bright-red  color,  in  the  centre  of  each  of  which  is  a  minute, 
bluish-white  speck.  These  spots  are  now  regarded  by  most  authorities 
as  pathognomonic  of  measles.  They  are  easily  overlooked  by  one  not 
familiar  with  them,  and  too  much  reliance  should  not  be  placed  on  this 
symptom  by  the  average  practitioner.  On  the  other  hand,  other  con- 
ditions may  be  mistaken  for  Koplik's  spots  by  the  inexperienced. 

The  constitutional  symptoms  of  measles,  while  somewhat  variable, 
are  fairly  characteristic.  They  are  at  their  height  during  the  stage  of 
eruption  and  are  usually  most  intense  on  the  fifth  or  sixth  day  of  the 
disease.  The  fever  then  abates  and  all  the  symptoms  begin  to  subside. 
This  sometimes  occurs  on  the  sixth  or  seventh  day  so  suddenly  as  to 
form  a  crisis.  This,  however,  is  not  the  rule.  When  the  disease  is  fully 
developed  the  patient  presents  a  striking  appearance.  The  face  is 
covered  by  a  blotchy  or  confluent  eruption  and  is  swollen  and  edematous; 
the  eyes  are  red  and  sensitive  to  the  light  and  are  filled  with  a  mucous 
or  mucopurulent  secretion ;  the  nose  is  swollen  and  discharges  a  similar 
secretion;  there  is  a  dry,  metallic,  and  very  troublesome  cough;  the 
tongue  is  coated;  the  appetite  is  completely  lost;  the  bowels  are  fre- 
quently relaxed;  the  child  lies  in  a  heavy  and  stupid  condition,  but  is 
restless  and  irritable  when  disturbed;  the  lymph  nodes  at  the  angle  of 
the  jaw  are  frequently  enlarged  and  not  infrequently  the  postcervical 
lymph  nodes  also. 

With  the  disappearance  of  the  fever  a  change  in  the  character  of  the 
cough  occurs.  It  loses  its  metallic  sound  and  harassing  character  and 
becomes  looser  and  less  irritating  to  the  patient.  It  frequently  dis- 
appears within  a  week,  but  sometimes  evidences  of  bronchitis  continue 
and  the  cough  proves  a  troublesome  symptom  for  several  weeks.  In 
most  cases  the  photophobia  subsides  rapidly  and  the  eyes  become 
normal,  but  often  remain  weak  and  watery.  If  strong  light  is  admitted 
too  soon  a  mild  but  very  troublesome  form  of  conjunctivitis  may  result. 
Other  symptoms  usually  subside  rapidly;  the  child  becomes  brighter 
and  less*^  irritable;  the  appetite  returns  and  evidences  of  illness  soon 
disappear. 

Mild  Type.— This  type  presents  no  material  variation  from  the  usual 
type  except  that  of  mildness.  The  eruption  is  not  well  marked,  the 
fever  is  slight,  and  all  the  symptoms  are  mild.  The  onset  is  sometimes 
of  the  usual  nature,  but  the  fever  does  not  become  high  and  the  disease 
subsides  rapidly.     The  catarrhal  symptoms  are  sometimes  slight  and 


ry24  ISFECTIOl'S   DISEASES 

some  of  the  older  authors  laid  considerable  stress  upon  morhiUi  sine 
caiarrho.  A  diajjnosis  of  measles  should  he  made  with  j^reat  hesitation 
when  there  is  no  eoryza,  suffusion  of  the  eyes,  or  cough.  Such  cases 
have  undoubtedly  occurred,  but  they  are  exceedingly  rare.  A  diagnosis 
can  l)e  made  with  certainty  only  with  the  knowledge  of  positive  ex- 
pos n  re. 

Severe  Type. — Measles  sometim(\s  appears  in  severe  form  even  when 
there  are  no  c()mj>lications.  The  fever  ranges  unusually  high,  the 
eruption  is  intense,  and  the  catarrhal  symptoms  are  excessive.  The 
child  may  l)e  delirious,  but  more  commonly  lies  in  a  comatose  condition 
for  a  day  or  two.  'i'he  disease  does  not  greatly  vary  from  the  average 
type  except  in  the  severeness  of  all  the  symptoms,  and  may  not  be 
longer  in  duration  than  are  the  milder  forms.  Such  cases  always  require 
very  close  attention.  It  should  not  be  forgotten  that  a  temperature 
which  ranges  unusually  high  is  generally  due  (o  a  comj)licati()n.  'i^his 
is  particularly  true  if  the  fever  continues  unabated  as  the  eruption  fades. 
The  complication  which  most  commonly  causes  an  excessive  or  unduly 
prolonged  fever  is  pneumonia.  Any  marked  variation  from  the  usual 
type  demands  particular  attention,  for  it  commonly  indicates  a  com- 
plication. It  is  not  safe  to  assume  that  it  is  a  simple  severe  case  until 
thorough  examination  has  eliminated  all  possible  complications. 

Malicjnanf  Type. — The  malignant  type  of  measles,  marked  by  intense 
and  overwhelming  symptoms  from  the  outset,  is  rarely  seen  outside  of 
institutions.  A  tyjx"  known  as  black  measles  is  occasionally  seen  in 
certain  epidemics.  The  name  is  deriv<>d  from  the  color  of  the  eruption, 
which  is  the  result  of  hemorrhage.  Small  petechial  spots  take  the  place 
of  the  regular  eruption.  In  many  malignant  cases  the  rash  is  faint  or 
late  in  its  appearance.  As  in  scarlet  fever,  the  system  may  be  over- 
whelmed at  the  outset  by  the  poison  of  the  disease  itself  and  the  char- 
acteristic symptoms  scarcely  develop  before  death  occurs.  In  others 
the  disease  seems  to  expend  itself  upon  the  lungs  and  the  pulmonary 
symptoms  develop  at  the  outset.  The  diagnosis  is  at  times  difficult 
and  sometimes  would  be  impossible  if  the  disease  were  not  known  to 
be  prevalent.  In  my  own  experience  the  so-called  malignant  cases  have 
often  been,  as  a  matter  of  fact,  complicated  cases.  In  an  epidemic  on 
Randall's  Island,  pneumonia  would  sometimes  develop  at  the  outset 
and  consolidation  could  be  detected  before  the  appearance  of  the 
eruption.  Carr  had  similar  cases  in  the  same  hospital  service.  In  such 
cases  the  eruption,  instead  of  being  intense,  is  often  faint.  There  are, 
however,  rare  cases,  as  already  stated,  in  which  the  patient  is  over- 
whelmed l)y  the  poison  of  the  disease  itself. 

Relapse  and  Recurrence. — True  relapse  in  measles  is  extremely  rare. 
Its  occurrence  in  fact  is  doubtful.  A  secondary  rise  in  temperature 
after  a  normal  fall  sometimes  occurs,  but  is  almost  invariablv  due  to 
some  complication.  In  such  cases  reappearance  of  the  rash  and  recur- 
rence of  the  catarrhal  symptoms  are  not  seen.  In  more  than  700  cases 
of  measles  carefully  observed  by  Comby  not  a  single  case  of  recurrence 
or  relapse  was  seen.     Secoufl  attacks  of  measles  undoubtedly  occur. 


MEASLES 


525 


This  is  probably  more  common  than  in  most  of  the  other  contagious 
diseases.  It  is  not,  however,  as  common  as  popular  reports  would  lead 
one  to  suppose.  It  is  extremely  doubtful  if  three  or  four  attacks  of 
measles  ever  occur  in  the  life  of  the  same  individual,  though  the  doctor 
is  constantly  hearing  of  such  cases.  Rotheln  is  frequently  mistaken 
for  measles  even  by  physicians,  and  many  attacks  due  to  disordered 
digestion  are  also  called  measles.  I  once  attended  a  child  whose  parents 
insisted  emphatically  that  he  had  had  measles  four  times.  Upon  the 
appearance  of  the  real  disease  of  ordinary  severity  they  were  seriously 
alarmed  because  the  attack  was  so  radically  different  from  any  one  of 
the  others,  and  they  were  then  in  doubt  as  to  the  genuineness  of  the 
preceding  attacks. 


Fig. 113 


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Uncomplicated  measles  in  a  girl  of  five  years,  the  rash  appearing  on  the  fourth  day.  This  is  the 
most  common  temperature  curve  of  measles.  It  is  characterized  by  a  gradual  rise  and  a  gradual  fall, 
the  highest  point  being  reached  as  the  rash  begins  to  appear,  on  the  afternoon  of  the  fourth  day, 
after  a  "  stairway  rise"  for  four  afternoons.  This  chart  is  almost  identical  with  charts  presented  as 
typical  for  measles  by  Holt  and  by  Ashby  and  Wright. 

Symptomatology.  Invasion. — The  invasion  of  measles  is  usually 
gradual,  so  much  so  in  fact  that  it  is  often  difficult  to  determine  the 
exact  time  of  onset,  and  the  character  of  the  disease  may  be  indefinite 
before  the  catarrhal  symptoms  are  present.  The  first  symptoms  are 
usually  suffusion  of  the  eyes,  with  acute  coryza  and  general  malaise. 
There  is  nothing  characteristic  about  any  of  these  symptoms,  and  unless 
exposure  is  known  or  expected  there  may  be  no  suspicion  that  the  child 
has  more  than  an  acute  cold.  The  positive  finding  of  Koplik's  spots 
is  a  great  help  to  an  early  diagnosis.  In  some  instances  the  onset  is 
abrupt,  but  an  abrupt  invasion  with  continuous  high  temperature  is 
most  often  due  to  a  complication,  usually  pneumonia.  The  period  of 
invasion  lasts  commonly  from  three  to  four  days.  It  is  occasionally 
as  short  as  one  day  and  as  long  as  five.     Only  in  rare  instances  is  it 


520 


/  A  FECTIO I  -S  DISK.  1 SES 


longer  than  live  days.     In  my  dwii  cxpcrieTico  in  the  ifvcat  majority  of 
cases  thr  rash  has  appeared  on  the  afterntjon  of  the  fourth  (hiy. 


Fi<i.  114 


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ture on  the  second  and  third  days.  This  is  not  uncommon,  the  remission  often  being  more  marked 
than  tliat  shown  in  the  above  chart.  The  temperature  sometimes  falls  to  normal  and  remains  near 
that  point  for  twelve  or  twenty-four  hours. 

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Uncomphcated  measles  of  somewhat  more  than  usual  severity  in  a  boy  of  eight  years,  marked  by 
a  gradual  rise  and  a  critical  fall  early  on  the  seventh  day.  The  rash  appeared  on  the  fourth  day, 
became  confluent  on  the  face  on  the  fifth,  and  on  the  body  on  the  sixth,  the  child  being  in  continual 
stupor.  Desquamation  began  on  the  face  on  the  seventh  day,  and  on  the  hands  and  feet  on  the 
twelfth.  Staining  was  still  distinct  on  the  fourteenth  day,  the  coryza  and  conjunctivitis  having  dis- 
appeared and  the  cough  having  almost  ceased.  Desquamation,  however,  was  still  progressing.  On 
the  twenty-second  day  desquamation  had  ceased  on  the  body  and  was  very  slight  on  the  hands. 


MEASLES 


527 


Temperature. — As  in  most  febrile  diseases,  the  fever  of  measles  some- 
times pursues  an  atypical  course.  In  the  uncomplicated  disease,  how- 
ever, a  markedly  atypical  temperature  range  is  not  common.  The  most 
common  temperature  curve  is  one  marked  by  a  gradual  rise  for  four  or 
five  days  followed  by  a  gradual  fall,  the  temperature  becoming  normal 
between  the  seventh  and  ninth  days.  In  an  abrupt  invasion,  how- 
ever, the  temperature  is  sometimes  found  at  102°  or  103°  F.,  or  even 
higher  on  the  first  day.  In  these  cases  of  abrupt  invasion  the  fever 
usually  subsides  on  the  second  and  third  days,  but  rises  rapidly  as 
the  rash  begins  to  appear.  A  critical  fall  is  also  sometimes  seen  in  the 
temperature  curve  of  measles.  This  may  occur  at  any  time  after  the 
fourth  day,  but  is  most  common  on  the  sixth  or  seventh  day.    \\Tien 


Fig.  116 


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Temperature  range  of  two  cases  of  measles,  the  patients  being  brothers,  aged  five  and  ten  years, 
exposed  at  the  same  time  and  lying  ill  in  the  same  room.  The  case  of  the  younger  was  mild  ;  that 
of  the  older  was  of  the  ordinary  type.  Though  the  older  was  taken  ill  twenty-four  hours  before  the 
younger,  the  rash  appeared  simultaneously  on  the  afternoon  of  the  fifth  day  of  the  first  case. 

the  fever  of  measles  continues  unabated  after  the  end  of  a  week  or  when 
it  rises  steadily  after  the  appearance  of  the  eruption,  a  compHcation 
should  always' be  suspected  and  carefully  sought  for.  It  is  true  that 
the  disease  is  occasionally  prolonged  and  continues  for  several  days 
after  the  eruption  is  at  its  height.  As  a  rule,  however,  the  fever  begins 
to  subside  within  a  few  hours  after  the  eruption  on  the  body  has  reached 
its  full  development  (Figs.  113,  114,  115  and  116). 

Pulse.— The  pulse  of  measles  shows  nothing  characteristic.  The 
pulse  curve  is  quite  similar  to  the  temperature  curve  and  in  the  absence 
of  complications  increases  and  diminishes  much  as  the  fever  rises  and 
falls. 

Eruption.— While  the  eruption  in  a  large  proportion  of  cases  follows 
a  typical  course,  it  not  infrequently  departs  from  it.    It  usually  requires 


528  INFECTIOUS  DISEASES 

thirtv-six  hours  to  attain  its  maxiimun  developiiKMit  on  the  face,  but 
occasionally  it  recjuires  twice  that  time.  It  not  infreciucntiy  hcjrins  to 
fade  on  the  face  by  the  time  it  has  made  its  a})pcarance  on  the  backs 
of  the  hands  and  tops  of  the  feet.  Unlike  the  eruption  of  some  diseases, 
it  frc(|U(Mitly  aj)pcars  on  the  soles  and  palms.  In  most  cases  as  the 
rash  disappears  a  faint  reddish  or  brown  stain  is  left.  This  frefjuently 
disappears  after  two  or  three  days,  l)ut  may  sometimes  be  seen  after  a 
week  or  ten  days.  This  staining  may  l)e  of  aid  in  determining  the  nature 
of  the  disease  when  seen  in  a  late  stage.    (See  Plate  XVII.) 

One  of  the  most  serious  departures  from  a  normal  rash  is  the  hemor- 
rhagic form  known  as  black  measles.  Instead  of  the  usual  hyperemia 
form,  small  hemorrhages  occur.  These  may  l)e  limited  to  small  areas 
or  may  extend  over  the  whole  body.  They  indicate  a  severe  form  of 
the  disease  and  warrant  a  grave  prognosis,  but  this  form  is  not  as 
genciallv  fatal  as  is  popularly  supposed.  It  is  more  commonly  observed 
in  hospitals  and  is  rarely  seen  in  private  practice.  On  the  other  extreme 
from  this  condition  is  a  very  faint  rash  which  is  visible  for  but  a  day 
or  two  and  sometimes  only  a  few  hours.  In  malignant  cases  the  rash 
mav  be  very  faint  or  may  not  appear  at  all,  but  this  is  less  common  in 
measles  than  in  scarlet  fever.  In  very  rare  cases  a  fine  rash  may  appear 
resembling  that  of  scarlet  fever  more  than  the  usual  one  of  measles. 
The  eruption  of  measlas  sometimes  recedes  suddenly.  This  usually 
results  from  failing  heart  power  and  poor  circulation.  The  rash,  it 
should  be  remembereil,  is  hyperemic,  and  anything  which  seriously 
changes  the  peripheral  circulation  will  modify  the  eruption.  '^Fhe 
p()j)ular  belief  that  in  such  ciises  the  rash  "has  struck  in"  is,  of  course, 
without  foundation  in  fact. 

Desquamation. — The  desquamation  of  measles  is  very  rarely  profuse, 
as  in  scarlet  fever.  When  the  case  is  nu'ld  or  when  inunctions  are 
fre(piently  j)erformed  the  (les(juamation  may  be  so  faint  as  to  be  almost 
imperceptil)le.  It  is  fine  and  branny  and  tiie  skin  does  not  strip  off 
in  shreds  and  scales  as  in  scarlet  fever.  In  many  cases  a  peculiar  and 
characteristic  so-called  "moiLsy"  odor  is  present. 

Conjunciivitis. — The  eyes  become  red  and  watery  very  early  in  the 
course  of  the  disease.  This  condition  increases  in  severity  until  the 
eruption  reaches  its  height  and  disappears  rapidly  as  the  fever  subsides. 
There  is  usually  an  itching  or  burning  sensation,  but  occasionally  a 
child  seems  to  suffer  V)ut  little  from  the  eyes.  Recovery  is  usually 
complete,  but  occasionally  chronic  conjunctivitis,  granulated  lids,  and 
other  local  conditions  are  left  behind.  The  siirjit  is  rarely,  if  ever, 
impaired. 

Anrjina. — An  exudate  on  the  tonsils  or  j)harynx  is  not  an  essential 
part  of  measles.  True  diphtheria  may  occur  as  a  complication,  but  is 
no  necessary  part  of  the  disease.  Catarrhal  pharyngitis  is  an  essential 
part  of  measles.  Not  only  the  pharynx  but  the  uvula  and  tonsils  are 
usually  involved.  They  present  on  examination  intense  uniform  redness, 
while  over  the  hard  palate  numerous  small  red  spots  may  be  seen  at  or 
a  little  before  the  time  of  the  eruption  on  the  face. 


'Km 


MEASLES 


529 


Complications  and  Sequelae. — The  most  common  and  serious  com- 
plications of  measles  are  bronchopneumonia,  membranous  laryngitis, 
otitis,  and  diarrhea;  the  most  common  sequelse  are  tuberculosis  and 
conjunctivitis. 

Pneumonia. — Catarrh  of  the  bronchial  tubes  is  so  constant  an  accom- 
paniment of  measles  as  to  be  classed  as  an  essential  part  of  the  disease 
and  one  of  its  symptoms,  but  it  is  easy  for  the  inflammation  to  extend 
from  the  smaller  bronchi  to  the  alveoli,  thus  transforming  a  normal 
condition  into  a  most  serious  compHcation,  namely,  bronchopneumonia. 
The  younger  the  child  the  greater  this  danger.  It  occurs  chiefly  in 
children  under  three  years  and  is  comparatively  rare  in  children  over 
four  years.  It  is  very  common  in  institutions  and  renders  measles  the 
most  dreaded  of  all  epidemic  diseases  in  infant  hospitals,  diphtheria 
being  no  exception  to  the  rule. 

In  a  recent  epidemic  of  measles  in  the  Infants'  Hospital  of  New  York, 
every  case  in  children  under  eighteen  months  was  complicated  by 
bronchopneumonia  or  croup.  The  pneumonia  usually  made  its  appear- 
ance soon  after  the  eruption  reached  its  height,  but  developed  in  a  few 
cases  during  the  stage  of  invasion,  the  disease  being  regarded  in  two 
instances  as  simple  bronchopneumonia  until  the  eruption  suddenly 
appeared.  According  to  Holt,  10  per  cent,  of  all  cases  are  complicated 
by  bronchopneumonia.  He  agrees  with  Henoch  that  a  certain  amount 
of  pneumonia  is  found  at  autopsy  in  almost  every  fatal  case. 

Observations  made  by  ]Merv  showed  that  both  the  pneumococcus 
and  streptococcus  are  present  in  the  saliva  of  children  ill  with  measles 
with  much  greater  frequency  than  in  health.  This  is  one  explanation, 
therefore,  of  the  comparative  frequency  of  pulmonary  complications. 
Lobar  pneumonia  is  an  occasional  complication  of  measles  in  children 
over  four  years,  but  is  seldom,  if  ever,  found  under  three  years.  Pleurisy 
or  empyema  is  sometimes  a  sec^iiel  of  such  complicating  lobar  pneu- 
monia. The  signs  and  rational  symptoms  of  either  form  of  pneumonia 
complicating  measles  present  nothing  unusual. 

Pharyngitis  and  Laryngitis. — ^Miile  catarrhal  pharyngitis  is  an 
essential  symptom  of  measles,  pseudomembranous  pharyngitis  occurs 
occasionally  as  a  complication.  Instead  of  invading  the  nose  and  ears 
as  in  scarlet  fever,  it  shows  a  strong  tendency  to  invade  the  larynx; 
but  croup  frequently  develops  without  the  appearance  of  membrane  in 
the  pharynx.  The  pseudomembranes  which  develop  during  the  early 
stages  or  at  the  height  of  the  fever  are  usually  pseudodiphtheritic  in 
character,  being  due  to  streptococci.  Those  wdiich  develop  later  are 
usually  due  to  the  Klebs-Loeffler  bacilli  and  are  true  diphtheria.  This 
secondary  streptococcic  disease,  howe^■er,  is  quite  as  fatal  as  the  bacillary 
disease.  Not  only  is  the  child  in  imminent  danger  from  laryngeal 
complications,  but  bronchopneumonia  often  develops  as  the  direct 
result  of  streptococcic  infection.  The  difterential  diagnosis  between 
true  and  false  diphtheria  can  rarely  be  made  with  certainty  from  clinical 
appearances  alone.  Fortunately,  in  private  practice  both  complications 
are  rare  in  children  over  four  years. 
34 


530  JXFKCTIULS  DISEASES 

Otifi.<}. — While  of  less  common  occurrence  than  in  scarlet  fever,  otitis 
sometimes  occurs.  It  does  not,  however,  usually  prove  so  serious  or 
cause  sucii  permanent  damafj^e.  Su])puration  is  common  and  both  ears 
are  usually  involv(><l.  'I'he  disease  presents  in  its  symptoms,  however, 
nothing  diti'erent  from  the  usual  course. 

.  Diarrhea. — Complete  anorexia  is  common  during  the  febrile  stage. 
Diarrhea  is  of  fre(|uent  occurrence  and  may  be  so  serious  as  to  prove 
a  grave  complication.  It  may  be  due  to  simple  intestinal  indigestion, 
or  it  may  l)c  the  evidence  of  enterocolitis.  It  usually  conunences  as  the 
fever  is  beginning  to  subside.  If  not  checked,  it  increases  in  severity 
and  may  continue  for  days  or  weeks.  It  is  more  common  in  young 
children  and  is  far  more  frequent  in  hospital  than  in  private  })ractice. 

Tubcrculo.sis. — The  most  cduunon  secjuel  of  mccusles  is  tuberculosis. 
It  connnonly  occurs  as  a  tuberculous  bronchopneumonia,  general  miliary 
tuberculosis,  tuberculous  adenitis,  or  tuberculous  joint  disease.  These 
may  result  from  primary  infection  or  from  the  lighting  up  of  some  old 
tul)erculous  process.  Measles  un((uestionably  renders  the  tissues  very 
susceptil)le  to  tuberculous  bacilli;  so  that  infection  may  result  from  slight 
exposure.  Acute  miliary  tuberculosis  may  follow  measles  at  once,  the 
temperature  range  being  continuous  from  the  outset  of  the  primary 
disease  to  death  from  the  complication.  General  tuberculosis  with 
grave  pulmoiuiry  involvement  niay  follow  so  close  upon  measles  as  to 
leave  no  appreciable  interval  between.  It  is  sometimes  the  cause  of 
a  secondary  fever,  which  develops  soon  after  the  subsidence  of  the 
primary  fever.  Tuberculous  disease  of  the  bones  and  joints  subsequent 
to  measles  is  usually  of  late  occurrence. 

Conjunciiintis. — Catarrhal  inflammation  of  the  conjunctiva  is  seen 
in  most  cases  of  measles.  If  a  child  is  kept  quiet  and  the  eyes  are 
protected  from  the  light  it  usually  subsides  without  special  treatment. 
In  some  cases,  however,  it  persists  even  when  these  precautions  are 
taken.  Among  poorly  fed  and  ill-couflitioned  children  chronic  con- 
junctivitis is  a  common  se(|uel  of  measles.  In  poorly  nourished  and 
anemic  children  keratitis  and  corneal  ulceration  are  of  not  infrequent 
occurrence.  Iritis  is  also  a  possible  sequel,  but  is  not  common.  A 
tendency  to  granulation  of  the  lids  upon  slight  provocation  is  sometimes 
seen  for  years  after  an  attack  of  measles. 

Other  Complirationfi. — Nephritis  is  rare  as  a  complication  or  sequel 
of  measles,  but  fel)rile  albuminuria  is  not  infrequent  in  patients  with 
high  temperature.  Nervous  symptoms  occasionally  occur,  but  con- 
vulsions at  the  outset  are  rare.  Acute  mania  has  been  reported,  but  is 
usually  temporary  and  recovery  is  complete.  Paralysis,  though  it  some- 
times occurs,  is  by  no  means  common.  ^Meningitis  also  occurs  rarely 
as  a  secjuel.  It  more  commonly  follows  otitis.  Moderate  cervical 
adenitis  often  occurs  and  sometimes  persists  for  months,  but  cellulitis 
and  suppurative  adenitis  are  of  rare  occurrence.  There  is  a  special 
tendeticy  to  tuberculous  involvement  of  the  lymph  nodes.  Endocarditis, 
pericarditis,  and  even  myocarditis  have  been  reported  a  few  times  in 
literature.    The  skin,  although  the  seat  of  an  extensive  eruption,  is  rarely 


PLATE  XVIII. 


Patient  ^^^ith   Measles   Exhibiting   Eruption   and   Catarrhal 
Inflammation  of  the  Eyes.     (Welch  and  Sehamberg.) 


MEASLES 


531 


injured  seriously  or  permanently.  Furunculosis  and  pemphigus  have 
been  known  to  follow  measles,  but  are  unusual.  The  mucous  mem- 
branes more  commonly  become  seriously  involved  than  does  the  skin, 
and  catarrhal  inflammations  are  common.  Catarrhal  stomatitis  is  almost 
as  common  as  conjunctivitis  and  bronchitis,  and  ulcerative  stomatitis 
is  not  infrequent.  Gangrenous  stomatitis  has  also  been  known  to  occur. 
Both  the  latter  conditions  are  seen  chiefly  in  hospitals  and  tenement 
houses  and  are  of  rare  occurrence  in  well-to-do  private  practice.  Hemor- 
rhages from  the  mucous  membranes  are  fortunately  rare,  but  not  un- 
known. 

Other  Infectious  Diseases. — The  occurrence  of  measles  simultaneously 
with  other  infectious  diseases  is  not  very  infrequent.  There  seems  to 
be  a  particular  tendency  to  the  simultaneous  occurrence  of  measles 
and  pertussis.  This  is  especially  common  in  hospitals.  In  a  recent 
epidemic  in  Randall's  Island  Hospitals  this  combination  of  measles 
and  pertussis  occurred  in  many  instances  and  seriously  complicated 
the  question  of  prevention  and  isolation  of  each  disease.  Many  cases 
are  recorded  of  the  coexistence  of  measles  and  scarlet  fever,  measles  and 
chickenpox,  measles  and  typhoid  fever,  and  measles  and  erysipelas. 
The  close  association  of  measles  and  tuberculosis  has  already  been 
dwelt  upon. 

Prognosis. — The  prognosis  of  measles  differs  greatly  in  private  and 
hospital  practice.  Death  from  measles  in  private  practice  is  rare  in 
children  over  four  years  of  age.  Holt  asserts  that  the  mortality  is  from 
4  to  6  per  cent.,  but  under  two  years  it  is  often  20  per  cent,  or  more. 
It  is  highest  between  one  and  two  years,  but  even  at  this  age  uncom- 
plicated measles  is  not  a  highly  fatal  disease.  Pneumonia  is  the  cause 
of  death  in  almost  90  per  cent,  of  fatal  cases. 

A  violent  onset  with  a  high  temperature  warrants  a  guarded  prognosis. 
The  same  is  true  when  the  eruption  is  excessive  in  amount  and  confluent 
over  wide  areas.  Pronounced  general  symptoms  with  a  faint  eruption 
is  a  grave  condition.  The  same  is  true  of  a  hemorrhagic  or  "black" 
eruption,  but  it  is  not  as  necessarily  fatal  as  is  commonly  supposed. 
Age  is  a  very  important  factor  in  prognosis.  According  to  statistics 
recently  presented  by  Holt,  measles  would  seem  to  be  the  most  fatal 
between  one  and  two  years,  even  more  so  than  in  children  between  six 
and  twelve  months.  The  mortality  is  still  comparatively  high  between 
two  and  three  years.  After  three  years  the  rate  rapidly  falls  and  during 
later  childhood  is  very  small.  The  temperature  is  another  element  of 
importance  in  prognosis.  A  case  in  which  the  temperature  at  no  time 
reaches  104°  F.  is  a  favorable  one.  Every  half-degree  above  that  point 
adds  to  the  danger  if  it  is  prolonged.  Wiien  the  temperature  continues 
for  any  considerable  time  above  105°  F.  the  prognosis  is  bad.  In  other 
words,  measles  does  not  naturally  have  as  high  a  fever  as  does  scarlet 
fever,  and  ranges  of  temperature  decidedly  above  the  average  are 
especially  serious.  The  character  of  the  eruption  is  still  another  element 
to  be  considered  in  prognosis.  Any  considerable  departure  from  the 
ordinary  type  is  unfavorable.    This  is  particularly  true  when  the  erup- 


532  INFECTIOUS  DISK  ASKS 

tion  is  excessively  marked  or  hemorrliagie,  and  equally  so,  upon  the 
other  hand,  when  it  is  faint  or  ill-defined,  with  marked  constitutional 
symptoms.  A  suflden  recession  of  the  eruj)tion  is  also  a  i^rave 
symptom. 

Measles  has  a  marked  tendency  to  leave  behind  it  results  of  a  serious 
nature.  Treatment  should  not  be  directed  solely  to  saving  the  life  of 
the  child,  nor  should  the  prognosis  be  made  up  solely  with  reference  to 
that  event.  The  tendency  to  tul)ercnlous  invasion  should  never  be 
forgotten,  and  when  the  fever  persists  after  the  tenth  day,  even  if  it  is 
not  high,  tile  prognosis  should  be  guarded.  The  list  of  chronic  affec- 
tions left  in  the  wake  of  measles  is  a  long  one;  bronchitis,  pharyngitis, 
rhinitis,  adenoid  growths,  enlarged  tonsils  and  mesenteric  lymph  nodes 
are  among  the  number  which  should  receive  consideration.  When  the 
fever  persists  after  an  attack  of  measles  and  the  child  fails  to  make 
satisfactory  recovery,  search  should  be  made  for  the  various  conditions 
mentioned.  As  a  rule,  it  will  be  found  that  the  complicating  disease, 
when  obscure,  is  of  a  pulmonary  or  tul)erculous  nature. 

Prophylaxis. — The  prevailing  belief  among  the  hiity,  too  often  shared 
by  medical  men,  that  measles  is  a  mild  and  unimportant  disease,  leads 
to  great  laxness  in  prophylaxis.  In  New  York  City,  during  the  months 
of  S larch  and  April,  \i)l)i,  there  were  oil  deaths  reported  from  measles. 
This  probably  does  not  include  the  whole  number,  for  many  deaths  due 
primarily  to  measles  were  undoubtedly  reported  as  due  to  pneumonia 
or  some  other  complif-ation.  Any  disease  which  can  present  a  record 
like  this  should  not  be  treated  as  unimportant.  It  is  an  unpardonable 
wrong  to  unnecessarily  expose  the  children  of  one's  neighboi-s.  Far 
more  care  in  j)revention  should  be  taken  than  is  now  often  exercised. 
The  advisability  of  taking  particidar  precaution  against  the  ex])osure 
of  infants  is  suggested  by  the  high  mortality  of  measles  among  children 
under  three  years.  Delicate  children  of  the  so-called  scrofulous  type 
and  those  with  hereditary  tendency  to  tuberculosis  should  be  especially 
guanled  against  exposure.  Early  and  absolute  isolation  of  the  sick  is 
imperative.  Isolation  of  the  patient  should  not  be  less  than  twenty-one 
days  and  as  much  longer  as  purulent  discharges  may  continue.  The 
period  of  rpiarantine  after  exposure  should  not  be  less  than  fifteen  days, 
and  twenty  (hiys  is  preferable,  (^hildren  who  have  l)een  exposed  should 
be  isolated  from  other  children  for  that  period. 

The  sick-room  is  likely  to  prove  less  (huigerous  than  is  the  scarlet 
fever  sick-room.  Thorough  cleansing  and  ventilation  for  two  weeks 
is  all  that  is  necessary  to  ensure  safety.  The  infection  of  measles  is  not 
persistent,  nor  is  intermediate  infection  common;  so  that  pr<)h)nge(l 
precautions  are  not  necessary.  The  prevention  of  the  infectious  diseases 
is  considered  in  greater  detail  under  Scarlet  Fever  (p.  508).  Except  in 
c-ertain  details  which  have  already  been  mentioned,  the  prevention  of 
measles  involves  much  the  same  precaution  as  does  that  of  scarlet  fever. 
Treatment. — Measles,  like  other  eruptive  fevers  must  pass  through 
certain  definite  stages.  Notwithstanding  claims  that  are  constantly 
being  made  in  the  medical   press,  no  abortive  treatment  has   as  yet 


MEASLES 


533 


been  discovered.  Ichthyol  ointment  and  other  local  measures,  as  well 
as  the  use  of  certain  drugs  which  have  been  vaunted  from  time  to 
time  as  aborting  or  curing  measles,  have  all  been  found  wanting  upon 
extended  trial.  The  treatment  must  be  symptomatic,  and  such  treat- 
ment when  judiciously  advised  and  carried  out  may  result  not  only  in 
the  saving  of  life,  but  in  the  prevention  of  many  serious  sequelee. 

A  room  as  large  and  well  ventilated  as  possible  should  be  selected 
for  the  measles  patient.  It  should  be  kept  dark  and  no  direct  light 
should  be  allowed  to  fall  upon  the  eyes.  Full  light  should  not  be  per- 
mitted until  the  conjunctivae  have  assumed  their  normal  appearance. 
Itching  of  the  lids  should  be  relieved  by  cold  cloths  or  by  the  appli- 
cation of  cold  cream  or  some  bland  oil.  The  eyes  should  be  kept  clean 
by  a  frecjuent  application  of  boric  acid  solution.  The  same  solution  or 
one  of  normal  salt  may  be  used  for  the  nose. 

One  of  the  most  troublesome  symptoms  of  measles  is  the  hard,  metallic 
cough.  It  frequently  disturbs  the  patient  seriously  and  breaks  his  rest. 
Very  little  relief,  however,  can  be  afforded  before  the  fever  begins  to 
subside.  It  cannot  be  loosened  by  the  administration  of  nauseating 
expectorants.  They  tend  to  render  the  child  more  irritable  and  to 
increase  the  anorexia,  and  have  but  slight  effect  on  the  cough.  Small 
doses  of  opium  and  codeine  aid  in  allaying  the  cough,  and  are  quite 
permissible.  Brown  mixture  (Mist.  Glycyrrhiz.  Co.,  U.  S.  P.)  in  the 
form  of  tablet  triturates  is  as  effective  as  any  treatment  and  is  easy 
of  administration.  In  some  cases  bromide  of  sodium  acts  well  in 
relieving  the  restlessness  and,  in  a  measure,  allaying  tlie  cough.  It 
may  be  given  in  0.3  gm.  (5  gr.)  doses  every  four  hours  for  a  child  of 
five  years.  It  should  be  given  in  water  alone  and  not  in  a  syrupy  mixture. 
It  thus  does  not  disturb  the  stomach  and  the  child  does  not  object  to 
the  slight  salty  taste.  Chloral  in  doses  of  0.2  to  0.3  gm.  (3  to  5  gr.)  at  five 
years  may  occasionally  be  given  to  relieve  restlessness.  The  cough  may 
sometimes  be  modified  by  the  use  of  cool  water  or  cracked  ice.  As  a 
rule,  however,  the  objection  of  the  patient  to  being  disturbed  renders 
treatment  of  this  nature  of  little  avail. 

The  fever  of  measles  rarely  requires  attention.  Only  when  it  ranges 
exceedingly  high  and  affects  the  patient  seriously  is  it  wise  to  intervene. 
The  effect  of  the  fever  upon  the  patient  is  a  better  guide  for  treatment 
than  is  the  thermometer.  If  the  child  becomes  restless  or  delirious, 
small  doses  of  phenacetin  are  admissible.  Only  enough  should  be 
given  to  lower  the  temperature  moderately  and  allay  the  restlessness. 
Cold  sponging  is  the  best  treatment  for  high  temperature  and  is  far 
preferable  to  the  administration  of  large  doses  of  antipyretics.  Water 
to  drink  should  be  given  freely  if  the  stomach  is  not  disturbed.  Cold 
bathing  based  on  the  Brand  method  of  treating  typhoid  fever  (a  bath 
of  65°  F.  for  fifteen  minutes  every  three  hours  as  long  as  the  temperature 
remains  at  103°  F.)  has  been  used  in  measles,  especially  by  German 
practitioners.  This  is  wholly  unnecessary  in  most  cases,  and  the  inju- 
dicious use  of  baths  may  do 'great  harm.  Cases  are  very  rare  in  which 
anything  more  radical  than  sponging  is  required,  and  sponging  is  not 


534  IXFECTIorS   DISK  ASKS 

often  necessary.  In  the  case  of  hyperpyrexia  a  bath  is  admissible.  In 
the  case  of  subnormal  temperature  a  hot  bath  may  be  given  accom- 
panied by  energetic  friction  of  the  surface.  Stimulants  are  seldom 
required  in  measles.  They  are  indicated  in  malignant  cases  and  in  the 
presence  of  complications.  The  various  complications,  such  as  broncho- 
pneumonia and  otitis,  require  the  same  treatment  they  would  receive 
under  other  conditions.  A  consideration  of  the  details  of  this  treatment 
is  not  necessary  in  this  place. 

The  practice  so  long  in  vogue,  and  still  too  frequently  seen,  of  sweating 
the  patient  and  administering  hot  drinks  to  bring  out  the  rash,  is  strongly 
to  be  discouraged.  In  the  great  proportion  of  cases  the  eruption  will 
come  out  in  clue  time  and  nothing  is  to  be  gained  by  rendering  the 
patient  wretched  and  uncomfortable.  In  the  case  eruption  is  really 
retarded  or  is  faint,  the  patient  may  be  wrapped  in  a  sheet  wrung  out 
of  hot  water,  but  this  is  rarely  necessary.  The  use  of  the  iodides,  acetate 
of  potash,  and  Dover's  powder  is  rarely  productive  of  good.  In  fact, 
the  more  simple  the  treatment  of  measles  is  made  the  better  are  the 
results.  Uncomplicated  cases  of  average  or  even  of  severe  type  rcijuire 
very  little  medication.  Treatment  directed  toward  the  bronchial  catarrh 
is  often  all  that  is  required.  Active  cathartics  should  be  avoided  as  far 
as  possible,  for  their  use  is  not  infrequently  followed  by  diarrhea.  If 
constipation  is  present,  it  is  best  to  relieve  it  by  enemata;  but  if  the 
tongue  is  heavily  coated  small  doses  of  calomel  and  soda  may  be  given 
with  good  effect.  If  the  enemata  are  not  productive  of  a  result,  a  mild 
saline  cathartic,  such  as  citrate  of  magnesia,  may  be  administered. 

The  eyes  should  receive  more  careful  attention  than  is  frequently 
given  to  them.  I'he  room  should  be  kept  well  darkened,  and  even  after 
the  light  is  admitted  the  use  of  the  eyes  should  be  much  restricted,  and,  as 
stated,  boric  acid  solution  should  be  used  to  wash  the  lids.  The  acute 
inflammation  to  which  they  are  subjected,  as  well  as  the  debilitating  influ- 
ence of  the  disease,  renders  the  eyes  themselves,  as  well  as  the  ocular 
muscles,  particularly  weak  and  sensitive.  In  some  cases  their  use  should 
be  restricted  for  several  weeks  after  recovery.  The  child  should  not  be 
permitted  to  go  to  school  until  the  eyes  are  in  a  strictly  normal  condition. 
Phlyctenular  conjunctivitis  with  its  army  of  dangerous  complications, 
including  ulceration  of  the  cornea,  is  often  witnessed  in  the  dispensaries 
as  a  sequel  of  measles.  INIost  text-books  do  not  lay  sufficient  stress  on 
the  importance  of  keeping  the  lids  aseptic  by  careful  cleansing  and  on 
not  using  the  eyes  too  soon. 

During  convalescence  unusual  care  should  be  exercised  in  avoiding 
unnecessary  exposure.  The  various  se(|uekie  should  receive  proper 
attention  and  the  particular  susceptibility  to  tuberculosis  should  not 
be  forgotten.  If  the  child  continues  anemic  or  the  cough  persists,  cod- 
liver  oil  and  iron  are  particularly  indicated.  In  such  cases  a  change  of 
climate  will  often  accomplish  more  than  medicine.  If  tuberculosis 
is  to  be  feared,  either  from  hereditary  predisposition  or  other  cause,  the 
patient  should  not  be  dismissed  permanently,  but  should  be  kept  under 
occasional  observation.     As  tuberculous  symptoms  sometimes  develop 


RUBELLA 


535 


at  a  considerable  interval  after  the  immediate  effects  of  the  disease  have 
disappeared,  the  necessity  for  good  food,  cod-liver  oil,  and  an  open-air 
life  in  suitable  weather  should  not  be  forgotten. 


RUBELLA. 

By  FLOYD  M    CRANDALL,  M.D. 

Rubella,  German  IMeasles,  or  Rotheln,  is  an  acute,  infectious,  and 
contagious  disease,  presenting  somewhat  varied  symptoms.  It  is  an 
entity  and  not  a  modified  form  of  the  other  eruptive  diseases.  Typical 
cases  present  the  following  features:  After  an  incubation  of  about 
fourteen  days  a  rash  appears  on  the  face  and  extends  rapidly  over  the 
body,  reaching  its  height  within  twenty-four  hours,  and  usually  dis- 
appearing by  the  end  of  the  third  day.  There  is  sometimes  a  short, 
indefinite  stage  of  invasion;  the  temperature  is  not  usually  over  101°  F., 
and  rarely  continues  over  three  days;  a  slight  desquamation  sometimes 
occurs;  complete  recovery  without  complication  is  the  rule.  One  of 
the  most  characteristic  symptoms  of  rubella  is  enlargement  of  the  post- 
cervical  lymph  nodes. 

Etiology. — Nothing  is  known  of  the  bacteriology  of  rubella.  It  is 
rarely  seen  in  children  under  six  months,  but  above  that  age  the  pre- 
disposition seems  to  be  universal,  its  occurrence  not  being  modified 
by  sex  or  age.  It  occurs  usually  in  epidemics,  which  are  most  frequent 
during  the  winter  or  spring.  It  is  less  contagious  than  measles.  Ashby 
and  Wright  assert  that  susceptibility  seems  to  vary  strangely  at  different 
times  and  in  different  places,  so  that  in  some  epidemics  it  seems  to  be 
very  contagious  and  in  others  slightly  so.  This  probably  accounts  for 
the  varying  opinions  regarding  its  contagiousness  expressed  by  different 
authorities. 

The  term  German  measles  is  an  unfortunate  one,  for  it  leads  to  much 
misunderstanding,  particularly  among  the  laity.  Rubella  does  not 
protect  against  measles  and  scarlet  fever,  and,  on  the  other  hand, 
these  diseases  do  not  protect  against  rubella.  A  marked  demonstra- 
tion of  this  recently  came  under  my  own  observation.  On  Tuesday 
the  three  little  sons  of  a  well-known  surgeon  awoke  covered  with  a 
profuse  eruption  of  rubella.  The  eruption  was  at  its  height  on  Wednes- 
day morning,  had  faded  on  Thursday,  and  disappeared  on  Friday. 
On  Saturday  afternoon  the  second  boy  was  taken  ill  (see  Fig. 
115)  and  passed  through  a  typical  attack  of  measles.  This  boy 
I  had  attended  two  years  before  through  a  typical  case  of  scarlet  fever 
lasting  six  weeks.  The  two  other  boys  came  down  with  measles  on 
the  twelfth  day  after  the  Saturday  upon  which  the  first  one  became  ill. 

Period  of  Incubation.— The  extremes  are  from  six  to  eighteen  days, 
possibly  twenty-two  days.  The  average  is  probably  fourteen  days. 
The  period  varies  considerably  in  cases  occurring  in  the  same  epidemic. 

Period  of  Contagiousness. — Rubella  may  be  contagious  for  a  few 
days  before  the  rash  appears  and  continue  so  until  complete  recovery, 


536  INFECTIOUS  DISEASES 

a  pericMl  sometimes  of  two  weeks.     It  is  most  contagious  on  the  three 
(hivs  following  the  appearance  of  the  rash. 

Clinical  Types. — .\s  there  is  grave  doubt  as  to  the  existence  of  the 
"fourtli  disciuse,"  it  still  seems  best  to  describe  ruV)ella  tis  occurring 
under  two  types — the  mea.sles  type  and  the  scarlatinal  ty])e. 

The  Measles  Type. — After  a  stage  of  invasion  lasting  but  a  few  hours 
and  marked  by  malaise  and,  perhaps,  feverishness,  a  rash  appears  on 
the  face  and  neck  and  spreads  rapidly  over  the  body.  This  stage  of 
invasion  is  frefjuently  lacking,  the  rash  being  the  first  evidence  of 
illness.  Sometimes  the  child  wakes  in  the  morning  covered  with  the 
rash.  The  individual  lesions  are  of  a  size  and  appearance  to  be  very 
suggestive  of  measles.  As  a  rule,  the  spots  are  of  a  pale  rose-red 
color,  larger  than  those  of  scarlet  fever,  but  smaller  and  less  blotchy 
than  those  of  measles.  They  are  rarely  grouped  and  the  skin  does  not 
assume  the  scarlet  hue.  The  rash  is  most  intense  on  the  second  day, 
l)ut  rapidly  fades  and  is  often  not  discernible  after  the  third  day.  The 
fever  is  the  highest  on  the  second  day,  but  in  many  cases  the  child  is 
but  slightlv  ill  at  any  time.  In  others  there  is  considerable  malaise 
and  heaviness  on  the  first  three  days.  Occasionally  there  is  fever, 
nausea,  headache,  and  all  the  evidences  of  acute  illness.  l)es(juamation, 
when  evident  at  all,  appears  soon  after  the  eruption  has  subsided.  A 
faint  pigment  sometimes  appears  for  a  few  days  after  the  rash  has  gone, 
but  does  not  persist  as  does  the  staining  following  measles.  The  throat 
is  often  dry  and  red,  but  exudates  are  exceedingly  rare.  Recovery  is 
prompt  and  there  are  rarely  any  complications  or  secjuelae. 

Scarlatinal  Type. — In  this  t\^e  the  constitutional  symptoms  are 
similar  to  those  of  the  measles  type.  The  two  types  differ  chiefly  in 
the  appearance  of  the  rash.  The  eruption  is  copious  and  very  similar 
to  that  of  scarlet  fever.  It  is  usually,  however,  less  punctate  than  that 
of  scarlet  fever  and  more  of  a  rose  tint.  There  is  a  uniform  redness 
of  the  skin,  but  the  little  points  about  the  hair  follicles  are  faint  or 
entirely  alxsent.  In  sporadic  cases  it  is  often  impossible  to  make  a 
diagnosis  from  the  rash  alone,  and  sometimes  it  is  necessary  to  wait 
for  des(juamation  to  settle  the  question.  Even  in  the  distinctly  scarla- 
tinal type  small  areas  will  occasionally  be  found,  especially  c:i  the 
forehead  and  arms,  in  which  a  maculopapular  eruption  appears.  In 
cases  of  (loui)t  the  whole  body  should  be  examined,  for  areas  of  the 
mea-sles  type  of  eruption  may  lie  found  which  will  aid  in  making  a 
diagnosis.  The  scarlatinal  t}^e  is  less  common  than  the  measles 
tv]je. 

Rubella  sometimes  appears  in  a  more  severe  form  than  that  here 
described.     The  prodromal  stage  is  decided,  the  eruption  is  marked 
the  temperature   ranges  as  high  as  103°  F.  and  continues  for  three  or 
four  days,  and  the  child  seems  decidedly  ill.    Vomiting,  headache,  and 
delirium  may  be  present,  and  the  diagnosis  may  be  difficult. 

S3rmptomatology. — The  invasion  in  very  rare  instances  is  marked  by  a 
convulsion,  chill,  or  severe  headache.  Usually  if  there  is  any  stage  of 
invasion  the  .symptoms  are  those  common  to  mild  febrile  conditions. 


RUBELLA  537 

The  fever  is  rarely  high.    The  temperature  is  often  not  over  100°  F. 
but  in  more  severe  cases  may  reach  102°  or  even  103°  F.    It  is  highest 
on  the  second  day  and  often  lasts  but  one  day.     It  is  impossible  to 
present  a  chart  which  can  be  regarded  as  t^-pical.     The  pulse  and 
respiration  present  nothing  characteristic. 

The  throat  is  usually  red  and  the  eruption  may  sometimes  be  seen 
on  the  roof  of  the  mouth.  Exudates  are  not  seen  except  occasionally 
as  a  complication.  Forchheimer  describes  an  "enanthem"  which  he 
believes  to  be  characteristic  of  rubella.  It  is  seen  on  the  first  day  on 
the  uvula,  but  not  on  the  hard  palate,  and  consists  of  bright  rose-red 
points  of  minute  size. 

The  eruption  may  cover  the  entire  body  or  may  be  limited  to  small 
areas.  It  is  rarely  absent  from  the  face.'  In  rubella  and  measles  the 
rash  usually  appears  on  the  lips,  but  in  scarlet  fever  the  region  about 
the  mouth  usually  remains  free.  The  eruption  is  rarely  confluent 
except  on  the  face,  and  is  seldom,  if  ever,  hemorrhagic.  It  is  sometimes 
so  elevated  as  to  have  a  shotty  feel  as  the  finger  is  passed  over  the 
skin.  Itching  is  very  common  on  the  first  day.  Authors  difl^er  widely 
in  their  statements  as  to  the  duration  of  the  eruption.  In  a  recent 
epidemic  in  New  York  it  was  not  unusual  to  see  a  profuse  eruption 
disappear  entirely  at  the  end  of  forty-eight  hours,  but  commonly  some 
evidence  of  the  eruption  could  be  found  for  three  or  four  days. 

Desquamation  usually  occurs  slightly,  but  in  some  cases  cannot  be 
detected.  It  is  light  and  branny  and  rarely,  if  ever,  profuse.  A  doubtful 
case  followed  by  marked  desquamation  may  safely  be  regarded  as 
scarlet  fever  and  not  rubella. 

Stvelling  of  the  lymph  nodes  is  one  of  the  most  constant  and  distinctive 
symptoms  of  rubella.  So  constant  is  its  occurrence  that  the  diagnosis 
should  be  made  with  caution  when  it  is  not  present.  The  lymph  nodes 
most  frec(uently  involved  are  the  cervical,  the  postcervical,  and  the 
suboccipital.  A  nest  of  small  lymph  nodes  found  low  in  the  neck 
behind  the  sternomastoid  muscle  is  especially  characteristic  of  the 
disease.  In  the  case  of  the  three  boys  referred  to  on  the  pre%dous  page, 
the  involvement  of  the  hmiph  nodes  during  the  rubella  was  excessive. 
It  rapidly  subsided  and  during  the  measles  no  nodes  could  be  felt. 
Although  rubella  is  an  extremely  mild  disease,  the  peculiar  enlarge- 
ments of  the  lymph  nodes,  the  marked  eruption,  and  its  close  simidation 
of  more  serious  diseases  render  it  of  considerable  interest. 

Diagnosis. — ^The  differential  diagnosis  between  rubella,  measles,  and 
scarlet  fever  is  often  very  difficult  and  sometimes  mipossible.  It  is, 
however,  very  important.  It  is  unfortunate  to  isolate  a  child  for  five 
or  six  weeks  who  is  simply  suffering  from  rubella,  but  still  more  unfor- 
tunate to  allow  a  mild  case  of  scarlet  fever  to  go  at  large  through  making 
the  opposite  mistake.  -\s  rubella  usually  occurs  in  epidemics,  it  is  the 
part  of  wisdom  to  regard  every  suspicious  sporadic  case  as  mild  scarlet 
fever  or  measles  until  the  diagnosis  can  be  made  with  certainty.  Certain 
drug  rashes,  especially  that  of  belladonna,  closely  simulate  the  rash  of 
rubella,  and  there  are  many  unclassified  eruptions  which  may  easily 


53S  INFECTIOUS  DISEASES 

1)0  mistaken  for  it.  lii  every  doubtful  ease  the  possibility  of  a  drug 
eruption  should  be  investigated  as  well  as  the  eondition  of  the  digestive 
traet.  This  subjeet  is  further  eonsidered  under  the  diagnosis  of  JSearlet 
Fever  (p.  505). 

Prognosis. — The  prognosis  of  rubella  is  invariably  good.  Tlu>re  are, 
in  fact,  but  few  eruptive  diseases  so  little  liable  to  complication  or 
serious  symj)toms. 

Treatment.— Most  eases  require  no  treatment  other  than  quiet  in 
bed  while  the  eruption  lasts,  a  li(iuid  diet,  sponging,  and  anointing 
with  vaselin  or  cold  cream.  In  the  more  severe  cases  the  treatment 
is  that  required  by  all  febrile  conditions.  If  the  case  is  severe  enough 
to  recjuire  definite  treatment,  the  measures  advised  for  measles  may  be 
appropriately  adopted. 

Isolation  for  two  weeks  at  least  is  necessary  to  prevent  the  spread 
of  the  disease,  and  the  prophylactic  measures  advised  for  measles 
should  be  carried  out. 


FOURTH  DISEASE. 

By  FLOYD  M.  CRANDAIX,  M.D. 

In  1900,  Clement  Dukes,  physician  to  the  school  at  Rugby,  published 
a  description  of  what  he  believed  to  be  a  disease  not  before  described, 
to  which  he  tentatively  gave  the  name  of  "  Fourth  Disease."  As  described 
by  him  the  only  difference  between  rubella  and  the  fourth  disease  is  in 
the  rash.  In  fact,  the  disease  he  described  is  virtually  that  w^hich  I 
have  described  as  the  scarlatinal  form  of  rubella.  It  is  quite  true  that 
the  two  forms  of  rubella  seem  like  different  diseases,  but  not  more  so 
than  do  different  types  of  scarlet  fever.  The  extended  chart  of  differ- 
ential diagnosis  given  by  Dukes  describes  identically  the  same  disease 
exce])t  as  to  the  rash,  and  he  even  admits  that  in  the  same  patient  the 
eruption  sometimes  resembles  measles  and  later  scarlet  fever.  It  is 
rare  to  find  a  case  of  the  scarlatinal  type  of  eruption  in  which  areas  of 
the  measles  type  cannot  also  be  found  upon  careful  search.  In  other 
cases  the  eruption  is  mixed,  and  if  we  grant  the  existence  of  the  fourth 
disease  can  only  explain  such  a  case  as  suft'ering  from  both  diseases. 

The  {(uestion  has  been  considerably  discussed  during  the  past  four 
years.  A  very  careful  study  of  32  cases  of  rubella  was  made  by  Watson 
Williams,  many  of  the  cases  being  what  Dukes  would  call  the  fourth 
disease.  He  is  inclined  to  question  the  existence  of  the  fourth  disease, 
believing  that  the  cases  thus  described  are  either  rul^ella  or  mild  scarlet 
fever.  Pleasants,  of  Baltimore,  also  had  opportunity  to  especially  study 
such  cases,  and  concludes  that  the  existence  of  a  new  exanthematous 
disease  has  not  been  established.  After  an  extended  review  of  the 
four  diseases  in  the  Practitioner  for  February,  1902,  Ker  concludes 
that  the  fourth  disease  is  either  mild  scarlet  fever  or  atypical  rubella. 
From  a  study  of  the  literature  and  considerable  experience  with  the 


ERYTHEMA    IXFECTIOSUM 


539 


three  diseases,  it  seems  to  me  that  we  have  not  sufficient  evidence  to 
warrant  us  in  describing  a  fourth.  :More  proof  is  needed  before  we  can 
accept  it  as  a  chnical  entity. 


ERYTHEMA  INFECTIOSUM. 
By  JOHN  RUHRAH,  :\I.D. 

Erythema  Infectiosum  is  a  sHghtly  contagious  disease  of  childhood 
characterized  by  a  maculopapular,  reddish  rash,  and  by  shght  or  no 
subjective  symptoms.  This  condition  was  described  as  a  separate 
disease  by  Escherich  in  1896.  It  has  not  as  yet  Manuary,  1905)  been 
observer!  in  America. 

Etiology. — The  disease  occurs  in  epidemics,  most  frequently  in  spring 
and  summer.  It  usually  affects  children  between  the  ages  of  four  and 
twelve.  Infants  under  one  year  are  apparently  immune.  It  is  but 
feebly  contagious  and  close  contact  would  seem  to  be  necessary  to 
communicate  the  disease.  An  attack  of  this  disease  does  not  protect 
from  measles,  scarlet  fever,  or  German  measles,  and  vice  versa.  No 
organism  has  as  yet  been  described  in  connection  with  this  erythema. 
The  incubation  period  is  given  as  being  from  six  to  fourteen  days. 

Symptomatology. — Prodromes  are  rare.  The  rash  is  usually  the  first 
thing  noted.  It  appears  first  on  the  face,  covering  the  cheeks  with  a 
uniform,  rose-red  flush,  which  is  slightly  raised  above  the  surface  and 
has  rather  abrupt  borders.  The  lips  are  free  and  the  forehead  and 
chin  but  slightly  spotted  with  small  patches.  This  is  hot  to  the  touch, 
but  is  not  sensitive  and  does  not  itch.  It  disappears  on  pressure,  but 
returns  immediately.  The  rash  appears  next  on  the  extremities  and 
trunk  and  it  spreads  from  above  downward.  On  the  trunk  there  are 
more  or  less  discrete,  crescentic  patches,  varying  in  size  from  one-eighth 
to  half  an  inch.  The  rash  is  marked  on  the  buttocks  and  the  extensor 
surfaces  of  the  arms  and  legs.  In  these  latter  locations  it  varies  in 
color  from  rose-red  to  a  brownish -red,  and  it  runs  together,  forming  g}Ti 
and  networks  of  a  map-like  character.  The  eruption  fades  from  the 
face  in  from  four  to  five  days  and  a  little  later  from  the  body.  In  all 
the  rash  is  present  from  six  to  ten  days.  There  is  no  sulisequent  desqua- 
mation or  pigmentation.  In  some  cases  it  disappears  and  later  reappears. 
The  mucous  membranes  are  not  affected. 

Other  s}Tnptoms  are  rarely  present.  In  a  few  cases  there  has  been 
slight  fever  for  a  day  or  two.  Occasionally  other  things  have  been 
noted,  as  sore  throat,  slight  reddening  of  the  conjunctivae,  and  rarely 
joint  pains.    There  is  no  enlargement  of  the  lymph  nodes. 

Diagnosis. — This  depends  largely  on  the  recognition  of  the  rash. 
Scarlet  fever  has  high  fever,  marked  constitutional  symptoms,  and  a 
more  or  less  uniform  rash.  In  measles  the  fever,  constitutional  symp- 
toms, the  catarrhal  s}Tnptoras,  and  KopKk  spots  are  sufficient  to  dis- 
tinguish it.    In  rubella  the  presence  of   enlarged  nodes  and  the  punctate 


540  IXFECTIOUS  DISEASES 

eruption  on  the  soft  palate  are  points  of  difTerencc.  Urticaria  is  easily 
diagnosed  by  the  itching,  and  drug  rashes,  from  the  history  of  having 
taken  drugs.  P>\'thema  exudativum  niultifonne  begins  on  the  hands 
and  feet,  becomes  vesicular,  has  marked  constitutional  symptoms,  and 
lasts  much  longer. 

It  should  not  be  confused  with  what  Dukes'  has  described  as  "Fourth 
Disease,"  in  wJiich  thescarlatiniform  eruption  is  said  to  appear  suddenly 
over  the   body.      (See  article  on  P'ourth  Disease,  p.  538.) 

Prognosis. — This  is  favorable.  There  are  neither  complications  nor 
sc(|ucla'. 

Treatment. — This  is  symptomatic. 

1  London  I>anoet,  July  1-1,  1900. 


CHAPTER  XXL 

VARICELLA— VACCIXIA— SMALLPOX. 
VARICELLA. 

By  FLOYD  M.  CRAXDALL,  M.D 

Varicella,  or  Chickenpox,  is  an  acute,  infectious,  and  contagious 
disease  occurring  almost  exclusively  among  children.  In  typical  cases, 
after  an  incubation  of  fourteen  days,  a  vesicular  eruption  appears  and 
continues  to  develop  in  crops  for  three  or  four  days.  Each  vesicle 
dries,  forms  a  crust,  and  falls  off,  usually  leaving  no  pit  or  mark.  While 
the  eruption  is  appearing  there  may  be  mild  febrile  s}Tnptoms,  but  the 
disease  is  rarely  serious.  The  term  ^■a^icella  (diminutive  of  variola) 
-was  given  at  a  time  when  the  disease  was  not  fully  differentiated  from 
smallpox. 

Etiology. — Varicella  is  unquestionably  an  infectious  disease,  but  the 
micro-organism  has  not  yet  been  discovered.  It  must  reside  in  the 
vesicles,  for  the  disease  may  be  transmitted  by  inoculation  of  the  vesicle 
serum.  It  may  also  be  transmitted  by  direct  contact,  it  being,  in  fact, 
almost  as  contagious  as  measles.  Intermediate  infection  through  a 
third  person  is  also  possible.  The  dried  crusts  contain  the  infective 
agent,  and  'may  be  the  means  of  transmitting  varicella  as  the  desqua- 
mation scales  transmit  scarlet  fever.  Baader,  of  Bale,  found  in  584 
cases  that  98  per  cent,  of  the  patients  were  under  ten  years  of  age  and 
65  per  cent,  were  under  five  years.  Sex  and  season  have  no  influence 
on  its  occurrence.  Epidemics,  while  common,  are  not  usually  very 
widespread.    The  infective  principle  may  remain  active  for  many  weeks. 

Period  of  Incubation. — This  is  rarely,  if  ever,  less  than  twelve  days 
or  more  than  sixteen.    The  most  common  period  is  fourteen  days. 

Period  of  Contagiousness. — Varicella  is  contagious  from  the  outset 
until  the  last  crust  has  fallen  and  the  purulent  discharges  have  ceased, 
a  period  not  usually  less  than  fourteen  days.    It  may  l^e  longer  than  this. 

Clinical  History.— The  eruption  is  usually  the  first  symptom  noticed. 
Occasionally  there  is  a  period  of  invasion  lasting  for  twelve  or  even 
twenty-four  hours,  marked  by  lassitude,  feverishness,  and,  perhaps, 
pains  in  the  head  and  back.  The  eruption  is  vesicular,  but  the  lesions 
begin  as  small,  red  papules.  The  papular  stage,  however,  is  very  short. 
Usually  at  the  physician's  first  visit  a  number  of  vesicles  are  already 
well  developed,  but  rose-red  papules  are  also  present.  The  first  lesions 
appear  upon  the  face  and  trunk,  especially  upon  the  back,  where  their 
development  is  usually  most  typical  (Figs.  117  and  118).  ^  In  this 
earlv  stage  the  vesicles'  consist  of  little  round  blisters  filled  with  clear 

I  5-il ) 


542 


JXFKCTKX  'S  DISl'JASES 


fluid,  surroimdcd  by  a  small  zone  of  redness.  'Vhv  skin  hctwccMi  the 
Irsious  is  nonnal.  Most  of  the  vesicles  are  uuiloeular  and  collapse 
when  thev  are  pricked.  They  are  rarely,  if  ever,  confluent.  The  clear 
serum  of  the  vesicle  becomes  cloudy  and  within  twenty-four  or  thirty- 
six  hours  begins  to  dry  so  that  a  scab  is  formed.  The  vesicles  appear 
in  crops  even  in  the  same  locality.  Hence,  papules,  new  vesicles,  old 
vesicles,  and  scabs  may  be  found  in  the  same  patient  a  few  days  after 
the  onset.  The  attack  is  usually  at  its  hei<i;lit  on  the  third  or  fourth 
day  and  the  acute  symptoms  are  passed  within  a  week  or  ten  days, 
but  the  scabs  fre(iuently  do  not  all  fall  before  the  end  of  the  third  week 
and  sometimes  later. 


Fig.  117 


Chickenpox. 

Symptomatology.  Temperature. — The  fever  of  varicella  is  extremely 
variable.  In  mild  cases  there  is  often  none  whatever.  Usually  there 
is  slight  elevation  of  temperature  for  one  or  two  days  and  not  infre- 
quently, in  the  more  severe  cases,  the  fever  continues  for  four  or  five 
days  or  even  longer.  It  is  usually  intermittent  in  type  and  may  range 
between  99°  and  102°  or  103°  F.  In  the  more  severe  but  rare  cases 
it  may  reach  104°  F.  It  seems  to  me  impossible  to  present  a  chart 
that  could  be  called  typical  of  varicella. 

Eruption. — The  lesions  of  the  typical  eruption  have  been  well  described 
as  looking  as  if  drops  of  hot  water  had  fallen  upon  the  skin  and  raised 


VARICELLA 


543 


small,  round  blisters,  with  a  narrow,  inflamed  zone  around  each.  When 
the  skin  is  thick,  as  on  the  palms  and  soles,  there  is  no  red  zone,  the 
vesicle  lying  alone  in  the  normal  skin.  The  contents  of  the  vesicles 
is  at  first  clear  and  soon  becomes  cloudy,  but  not  purulent  unless  they 
are  irritated  or  infected.  The  number  of  vesicles  ranges  from  a  dozen 
or  a  score  to  many  hundred  and  are  most  profuse  and  t}'pical  on  the 
back  and  shoulders.  But  few  appear  upon  the  face;  in  some  cases  none 
are  seen  there.  The  vesicles 'begin  to  dry  in  the  centre  and  frequently 
present  an  umbilicated  appearance,  when  the  process  is  partially  com- 
pleted. Scabs  or  crusts  are  soon  formed,  which  fall  in  from  seven  to 
twenty-one  days  according  to  the  depth  to  which  the  process  extended. 


Fig.  118 


Chickenpox  vesicles  surrounded  by  reddish  areolse.    (Welch  and  Schamberg.) 


Pitting  is  rare.  This  sometimes  happens,  however,  when  the  vesicle 
has  involved  the  true  skin.  It  is  most  common  on  the  face.  Deep 
ulcerations  which  may  last  for  several  weeks  sometimes  occur.  They 
are  most  common  in  anemic,  poorly  nourished  children,  especially 
those  of  tuberculous  tendency. 

Complications. — Varicella  is  very  rarely  complicated,  although  two 
grave  complications  are  possible.  It  is  a  strange  fact  that  in  a  disease 
so  mild,  complications,  when  they  do  occur,  should  be  so  serious. 
These  complications  are  gangrenous  dermatitis  and  erysipelas. 

Gangrenous  Derinatitis. — The  so-called  varicella  gangra:-nosa  is  simply 
gangrenous  dermatitis  taking  its  origin  from  varicella  lesions.  It  is 
most  common  on  the  neck,  chest,  and  upper  part  of  the  trunk.     It  is 


544  INFECTIOUS  DISEASES 

but  little  amenable  to  treatment  and  runs  its  course  in  from  seven  to 
twenty  days  and  usually  terminates  fatally.  It  probably  never  occurs 
in  perfectly  healthy  children,  but  is  usually  seen  in  tuberculous  and 
ill-nourished  patients  of  h()s]>itals  and  dispensaries. 

Erysipelas. — While  not  frccjucnt  in  occurrence,  erysijx'las  is  probably 
the  most  common  complication  of  varicella.  Nephritis  has  occasionally 
been  reported  as  a  complication.  Adenitis  of  marked  type  may  also 
occur.  Other  complications  rej)()rted  from  time  to  time  are  probably 
not  more  than  coincidences.  Varicella,  like  all  the  eruptive  fevers, 
mav  occur  in  conjunction  with  one  of  the  exanthemata.  The  combi- 
nation of  varicella  and  scarlet  fever  is  probably  the  most  common. 
Relaj)sc  and  recurrence  are  extremely  rare. 

Diagnosis.— The  only  disease  witii  which  varicella  is  likely  to  be 
confounded  is  smallpox  of  mild  type.  Small|)Ox  begins  with  a  stage 
of  invasion  marked  by  fever,  backache,  iicadachc,  and  drowsiness  and 
often  vomiting  and  delirium;  varicella  begins  with  an  eruption  pre- 
ceded by  a  very  short  and  mild  stage  of  invasion  and  often  by  none 
whatever.  In  smallpox  the  lesions  begin  as  papules  and  remain  so 
for  one  or  two  days,  when  they  develop  into  vesicles  and  finally  by  the 
eighth  day  into  pustules;  in  varicella  the  paj)ules  change  into  vesicles 
in  a  few  hours,  become  cloudy  and  dry  into  crusts  before  it  is  time  for 
tlie  variola  vesicle  to  become  a  pustule.  In  smallpox  the  lesions  are 
all  of  the  same  age;  in  Aaricella,  papules,  vesicles,  and  crusts  are  all 
present  in  the  same  locality  at  the  same  time.  In  smalljiox  the  lesions 
are  multilocular  and  truly  umbilicated;  in  varicella  they  are  mostly 
unilocular  and  appear  umbilicated  only  as  they  begin  to  dry  in  the 
centre. 

Prognosis. —  The  prognosis  is  always  good  in  paticMits  in  ordinary 
health.  Only  in  the  marasmic,  ill-nourished,  and  tuberculous  are 
untoward  symptoms  to  be  expected. 

Treatment. — The  varicella  patient  is  capable  of  transmitting  the 
disease  while  the  crusts  remain.  It  is  wrong  to  pennit  the  exposure  of 
infants  and  weakly  children.  It  is  also  wrong  to  expose  the  children 
of  other  people  even  to  a  trivial  disease,  for  one  can  never  know  what 
inconvenience  it  may  produce.  Hence,  there  are  many  cases  in  which 
isolation  should  be  enforced  from  the  first  symptoms  until  the  crusts 
have  fallen.  Mc(licinal  treatment  is  rarely  re((uired.  In  the  more 
serious  cases  symptoms  should  be  treated  as  they  arise.  Itching  or 
irritation  of  the  skin  may  be  relieved  somewhat  by  a  carbolic  wash  or 
camphorat(ul  vjuselin.  I^csions  which  become  irritated  or  broken 
should  be  dressc-d  with  a  boric  acid  or  other  mild  ointment  and  managed 
with  antiseptic  care. 


VACCINIA 


VACCINIA. 


545 


Vaccinia,  or  Cowpox,  is  an  acute,  infectious  disease  of  the  cow  char- 
acterized by  a  vesicular  eruption  upon  the  udder  and  teats.  The 
disease  may  be  communicated  to  man  by  inoculation  of  the  lymph 
from  these  vesicles  and  affords  protection,  for  a  variable  period,  against 
smallpox. 

Whether  smallpox  and  cowpox  are  the  same  disease  or  are  separate 
entities  is  still  a  subject  of  discussion.  The  weight  of  evidence, 
Osier  believes,  favors  the  view  that  cowpox  is  variola  modified  by 
transmission. 

The  first  vaccination  on  a  human  subject  was  performed  by  Edward 
Jenner  on  May  14,  1796.  It  was  a  matter  of  popular  though  local 
observation  that  persons  who  had  been  inoculated  by  cowpox  rarely 
contracted  smallpox.  I.ittle  James  Phipps  was  the  first  subject. 
His  vaccination  ran  a  typical  course  and  after  several  subsequent  unsuc- 
cessful trials  the  boy  was  taken  through  a  smallpox  hospital  without 
the  slightest  harm.  Two  years  later  Jenner  published  his  observations 
in  a  little  book  of  seventy-five  pages,  entitled  An  Inquiry  into  the  Cause 
and  Effects  of  the  Variola;  Vaccince,  a  Disease  Discovered  in  Some  of  the 
Westerfi  Counties  of  England,  Particularly  Gloucestershire,  and  Known 
by  the  Name  of  Cowpox.  From  the  publication  of  this  little  book  the 
adoption  of  vaccination  was  very  rapid.  The  first  vaccination  in 
America  was  performed  in  Boston  on  July  8,  1800,  by  Dr.  Benjamin 
Waterhouse,  Professor  of  Physic  at  Harvard.  The  operation  was  intro- 
duced into  the  Southern  States  through  the  personal  efforts  of  Thomas 
Jefferson,  then  President,  who  fully  understood  the  ravages  of  the 
disease  among  the  black  population. 

Protective  Power  of  Vaccination. — In  determining  this  question  certain 
historical  and  statistical  study  is  necessary.  We  must  know  what 
smallpox  was  before  vaccination  and  what  it  has  been  since.  In  a 
paper  entitled  "A  Century  of  Vaccination,"  published  in  American 
Medicine,  December  7,  1901,  I  considered  the  subject  from  many 
standpoints  and  summarized  a  large  quantity  of  statistics.  Space  here 
permits  reference  to  but  a  few  facts. 

A  hundred  years  ago  smallpox  was  justly  regarded  as  "the  attila  of 
diseases,  the  very  scourge  of  God,  overrunning  countries  and  destroying 
populations."  When  Jenner  performed  his  first  vaccination,  it  was 
causing  one-tenth  of  all  the  deaths  of  the  human  race.  Bernouilli,  the 
mathematician,  estimated  that  more  than  60,000,000  of  the  inhabitants 
of  Europe  died  of  smallpox  during  the  eighteenth  century.  Others 
place  the  number  even  higher.  Specific  proof  of  its  fatality  is  shown 
by  Cowan's  vital  statistics  of  Glasgow.  In  that  city  between  1783  and 
1792,  36  per  cent,  of  all  deaths  under  ten  years  were  due  to  smallpox. 
One-third  of  all  the  deaths  in  Europe  under  ten  years  were  due  to  the 
same  cause.  When  smallpox  was  introduced  into  Mexico  by  the 
Spaniards  in  1520,  3,500,000  died  within  a  few  years.  In  1737,  in 
35 


546  INFECTIOUS  DISEASES 

Iceland,  1S,000  in  a  population  of  oO.OOO  died  in  a  single  year.  It  is 
believed  that  (),000,0()0  North  American  Indians  fell  victims  to  its 
ravages. 

One  hundred  years  ago  smallpox  was  the  most  widespread  dis- 
ease which  affected  the  human  race.  To-day  many  physicians  of 
large  experience  have  never  seen  a  case.  Some  marvellous  power  has 
been  at  work  to  produce  this  change.  Isolation  and  improved  sanitation 
are  valuable  aids  in  suppressing  the  disease,  but  they  cannot  explain 
these  changed  conditions.  In  Sweden  the  death  rate  from  smallpox 
for  twenty-five  years  preceding  vaccination  per  million  living  was 
2045.  Under  optional  vaccination  it  fell  to  408,  under  compulsory 
vaccination  to  loo,  and  for  ten  years  under  more  rigid  laws  to  5.  In 
Germany  after  the  rigid  law  of  1874  the  rate  per  million  fell  from  309 
to  15,  and  for  ten  years  has  averaged  7.  In  the  German  army,  in  which 
the  vaccination  law  is  most  thoroughly  enforced,  there  has  been  but 
one  death  from  smallj)ox  since  1874.  The  following  figures  are  given 
on  the  authority  of  the  Practitioner  and  of  Sir  George  Buchanan  for 
the  Sheffield  epidemic  of  1887-88: 

Attack  rate  per  1000  in  the  non-vaccinated  .  .  .  .94;  death  rate,  51  00 
"         •'      "      "    "    "    once  vaccinated .       ...    19  "  1.00 

"         "      "      "    "    "    revaccinated       ....      3  "  0.08 

1  in  1300  of  the  vaccinated  died ;  1  in  20  of  the  unvaccinated. 

Clinical  History. — The  clinical  history  of  normal  vaccination  is  fairly 
uniform.  Any  marked  deviation  from  the  normal  course  may  vitiate 
the  value  of  the  result.  It  is  entirely  reasonable  to  insist  that  in  a 
procedure  like  vaccination  certain  requirements  should  be  fulfilled. 
A  vaccination  sore  should  pass  tii rough  certain  well-<lefined  stages. 
If  it  does  not  do  so  it  is  not  an  adequate  vaccination,  and  cannot  be 
expected  to  confer  full  protection. 

Incubation. — There  is  usually  .some  slight  irritation  after  vaccination 
which  sul)sides  completely  and  nothing  may  l)e  apparent  for  two  or 
three  days. 

Eruption. — On  the  third  or  fourth  day  after  vaccination  a  faint 
redness  appears  at  the  point  of  inoculation.  This  redness  gradually 
increases  and  a  little  reddish  papule  is  formed.  The  papule  gradually 
changes  into  a  vesicle  which  on  the  fifth  or  sixth  day  contains  a  thin, 
transparent  Huid.  By  the  eighth  day  the  fluid  has  become  yellowish 
in  color  and  in  the  centre  a  little  depression  may  be  seen.  About  this 
time  a  circle  of  inflammation,  the  areola,  appears  about  the  vesicle. 
By  the  tenth  day  the  inflamed  skin  is  tense  and  painful  and  the  vesicle 
has  become  a  pustule.  By  the  twelfth  day  the  vesicle  begins  to  dry, 
aufl  by  the  fifteenth  day  a  crust  has  formed  (Figs.  119,  120  and  121). 
This  cru-st  is  of  mahogany  color,  rough,  but  thinner  in  the  centre  than 
at  the  edges.  It  rarely  falls  before  the  end  of  the  third  week.  The 
scar  is  at  first  red,  but  soon  fades,  and  has  a  pitted  or  streaked 
appearance. 

The  following  series  of  lesions  Ls  necessary  for  satisfactory  vacci- 
nation— papule,  vesicle,  pustule,  scab,  and  scar. 


VACCINIA 


547 


Constitutional  Symptoms. — In  most  cases  there  Is  a  period  of  feverish- 
ness,  fretfulness,  and  malaise.  This  usually  begins  on  the  fourth  or 
fifth  day,  but  may  begin  as  early  as  the  third  or  as  late  as  the  eighth 


Fig. 119 


iufant  born  of  a  variolous  mother  in  the  Municipal  Hospital,  Philadelphia ;  vaccinated  on  day  of 
birth;  protection  complete  ;  photographed  on  ninth  day.    (Welch  and  Schamberg.) 

Fio. 120 


Eevaccination  in  an  adult,  showing  vesicles  upon  the  eighth  day.    (Welch  and  Schamberg.) 


548 


INFECTIOVS  DISEASES 


Fig.  121 


or  triitli  <lay.  Thr  loinpcTatuiv  iisiuilly  rises  to  100°  or  101°  F.,  and 
the  comlitioM  continues  for  three  or  four  (hiys.  The  lymph  nodes  of  the 
axilla  or  ii;roin  are  sometimes  slightly  enlarged  and  may  he  painful. 
In  otluM-  eases  the  symptoms  are  more  decided.  The  fever  is  higher, 
sometimes  reaching' 103°  or  even  104°  F.,  is  intermittent  in  type,  and 
c-ontinues  for  four  or  five  days.  In  rare  eases  an  even  more  severe  type 
is  scHMi.     In  babies  the  fever  and  general  symptoms  are  often  absent, 

there  being  simply  a  day  or  two  of 
discomfort  or  loss  of  appetite.  Under 
modem  methods  of  vaccination  the 
general  symptoms  as  well  as  the 
local  sore  are  usually  less  marked 
than  they  formerly  were. 

Irreg'ular  Vaccination.  Local  Vari- 
ations.— The  local  sore  may  vary 
greatly  from  that  just  described.  A 
large  and  angry  sore  is  sometimes 
seen,  but  it  confers  no  greater  im- 
munity than  does  one  of  normal  size. 
On  the  other  extreme  a  very  small 
scn-e  is  not  uncommon  with  glycerized 
Ivmph.  The  size,  however,  does 
not  invalidate  the  result,  if  it  passes 
tiirough  tile  various  stages  in  proper 
order.  The  value  of  a  vaccination 
should  be  doubted  if  it  progres.ses 
abnormally  fast,  so  that  a  crust  is 
formed  at  the  end  of  a  week.  It 
should  also  be  doubted  if  the  con- 
tents of  the  vesicle  is  bloofly  or  if 
the  sore  discharges  pus.  Traumatism  after  the  seventh  day  may  not 
render  the  vaccination  valueless,  but  it  is  wise  to  make  a  second  trial, 
A  sore  after  a  vaccination  is  not  in  itself  a  guarantee  that  immunity 
has  been  conferred.  It  should  pass  through  the  five  stages  in  definite 
orfler.  Anv  marked  variation  from  the  normal  coiu'se  casts  suspicion 
upon  the  adecjuacy  of  the  vaccination. 

A  condition  known  as  the  "raspberry  excrescence"  sometimes  takes 
the  place  of  the  ordinary  vaccination  sore.  It  rises  out  of  the  normal 
skin  and  is  usually  of  a  dark-red  color  and  of  slightly  lobulated  appear- 
ance. It  is  not  sore  and  does  not  discharge  pus.  It  usually  disappears 
after  two  weeks,  but  occasionally  persists  for  several  months.  It  is 
supposetl  to  be  due  to  weak  virus,  or  to  virus  containing  some  particular 
form  of  bacterium.     It  does  not  confer  immunity. 

As  a  rule,  the  vaccination  sore  is  the  only  lesion  which  occurs  on  the 
skin,  but  sometimes  secondary  pustules  appear  about  the  primary  sore. 
Less  frefjuently  a  generalized  eruption  occurs  and  the  child  may  be 
actuallv  ill.  This  is  sometimes  pustular  and  resembles  smallpox. 
At  other  times  the  eruption  consists  of  dusky,  mottled  patches  or  a 


Vaccine  vesicle  on  uiiilh  clay,  showing  pro- 
nounced areola.   (Welch  and  Schamberg.) 


VACCINIA  549 

rose-colored  eruption  which  continues  for  two  or  three  days  and  is 
followed  by  slight  desquamation.  I  once  saw  a  case  in  which  a  pro- 
fuse eruption  on  the  trunk  and  neck  appearing  eight  days  after  vaccina- 
tion consisted  of  large,  oval  blotches  of  deep-red  color,  surrounded 
by  a  lighter  areola  which  shaded  off  into  normal  skin.  Secondary 
pustules  are  not  infrequently  caused  by  inoculation  by  the  finger-nails 
from  the  primary  sore. 

Constitutional  Variations. — A  vaccination  may  be  efficient  even  with- 
out the  constitutional  symptoms.  This  is  not  uncommon  in  infants. 
The  character  of  the  sore,  not  the  general  symptoms,  should  be  the 
guide.  On  the  other  hand,  severe  symptoms  may  occur  without  modify- 
ing the  result. 

Complications. — The  various  complications  of  vaccinia  and  the  time 
of  their  occurrence  are  thus  classified  by  Acland:  During  the  first 
three  days,  erythema,  urticaria,  vesicular  and  bullous  eruptions,  invac- 
cinated  erysipelas.  After  the  third  day  and  until  after  the  pock  reaches 
maturity,  urticaria,  lichen  urticatus,  erythema  multiforme,  accidental 
erysipelas.  About  the  end  of  the  first  week,  generalized  vaccinia, 
impetigo,  vaccinal  ulceration,  glandular  abscess,  septic  infection, 
gangrene.     After  the  involution  of  the  pocks,  invaccinated  diseases. 

Cellulitis  is  the  most  common  complication.  It  is  due  to  bacterial 
infection  and  may  be  the  result  of  infected  virus,  carelessness  in  perform- 
ing the  operation,  or  to  later  infection.  In  mild  cases  there  is  simply 
more  intense  inflammation  in  the  areola  than  is  normal.  In  a  more 
severe  type  pus  forms  under  the  scab  and  about  the  sore  and  the  areola 
is  of  unusual  size.  In  still  more  severe  cases  an  excavated  ulcer  may 
be  found,  which  is  extremely  stubborn  and  difficult  to  heal.  These  sores 
sometimes  last  two  months.  More  or  less  enlargement  of  the  adjacent 
lymph  nodes  is  likely  to  follow  and  suppuration  may  occur  in  them, 
but  this  is  very  rare.  While  cellulitis  due  to  infection  by  pyogenic 
bacteria  is  common,  erysipelas  is  not  often  seen.  It  is  a  very  possible 
complication,  however. 

Most  of  the  arguments  against  vaccination  date  back  to  the  time 
of  Birch  and  Rogers,  in  1805,  and  are  based  to  a  considerable  extent 
upon  an  experience  when  arm-to-arm  vaccination  was  practised.  By 
that  method  blood  diseases  were  occasionally  transmitted.  The  bovine 
species  from  which  all  vaccine  lymph  used  in  this  country  is  now  obtained 
is  not  susceptible  to  syphilis  and  that  disease  is  never  transmitted  by 
vaccination  with  bovine  lymph.  Syphilis  is  a  peculiar  disease  in  its 
manifestations.  Infants  affected  with  syphilis  are  very  frequently  born 
apparently  healthy,  and  the  first  signs  usually  show  themselves  during 
the  third  or  fourth  weeks.  Many  cautious  physicians,  therefore,  refuse 
to  vaccinate  a  child  before  the  end  of  the  sixth  week.  The  disease  has 
many  times  been  charged  to  vaccination  and  physicians  have  received 
undeserved  censure,  when  it  was  in  fact  the  disease  was  inherited.  Tuber- 
culosis is  not  transmissible  by  modern  vaccine  lymph.  Acland  thinks  it 
doubtful  whether  it  has  ever  been  so  transmitted.  It  is  extremely  doubt- 
ful whether  the  tubercle  bacilli  ever  appear  in  the  lymph  even  in  animals 


5-)0  IXFECTIOCS   I)ISI':ASES 

suffering  from  the  disease.  To  guard  against  any  such  chance,  however, 
the  lea(hng  makers  examine  postmortem  every  calf  from  which  lymph 
ha.s  been  taken.  If  any  evidence  is  found  of  tuberculosis  or  any  other 
disease,  the  lymph  from  that  aninuU  is  r(>)(>cte(l.  A  few  great  firms 
make  much  of  the  lymph  now  used  in  this  c-ouutrv,  and  could  not  afford 
to  have  accidents  happen  from  the  use  of  their  products.  It  is  uiuiues- 
tionably  true  that  tetanus  has  been  conveyed  by  vaccine  lymph.  In 
1!H)1  several  cases  occurred  in  the  United  States  and  two-tiiirds  of  them 
were  traced  to  lymj)h  procured  from  one  source.  This  experience 
suggests  the  importance  of  government  supervision  over  the  production 
of  vaccine  lymph.  There  is  no  authentic  case  on  record  in  which  cancer 
ha-s  resulted  from  vaccination.  The  tendency  of  certain  diseases  to  lie 
dormant  and  appear  at  certain  times  or  to  be  waked  into  activity  by 
slight  exciting  causes  is  to  be  considered  in  studying  the  supposed 
complication  of  vaccination.  This  is  notably  true  of  tuberculosis, 
syphilis,  and  eczema. 

Technique. — The  outer  aspect  of  the  left  arm  at  the  insertion  of  the 
deltoid  and  the  outer  aspect  of  the  left  leg,  one-third  of  the  way  from 
the  knee  to  the  hip,  are  the  points  usually  selected  for  vaccination.  A 
site  over  a  bone  like  the  shin  or  a  spot  over  a  tendon  should  never  be 
selected.  In  young  children  the  leg  is  most  readily  reached  and  can 
be  most  easily  cared  for.  In  older  children  the  arm  can  be  most  easily, 
protected  from  dirt.  It  should  be  selected  for  children  who  will  not 
be  closely  cared  for. 

Vaccination  is  a  surgical  operation  and  should  be  done  with  surgical 
cleanliness  and  care.  The  skin  should  be  washed  with  warm  soap  and 
water  or  with  alcohol.  Other  antiseptics  should  not  be  used,  for  if  they 
are  not  thoroughly  removed  they  may  harden  the  skin  and  neutralize 
the  vaccine  virus.  The  best  instrument  is  a  common  cambric  needle 
and  a  fresh  one  should  be  used  for  each  patient.  The  needle  should  be 
sterilized  by  boiling  or  heating  in  an  alcohol  flame  just  before  using. 
The  skin  is  put  slightly  on  the  stretch  and  with  the  point  of  the  needle 
four  or  five  scratches  a  quarter  of  an  inch  long  are  made.  They 
should  not  be  (h^ep  enough  to  draw  blood,  but  no  harm  is  done  if  a  few 
minute  points  of  blood  appear.  These  are  crossed  by  other  scratches 
not  made  too  close  together.  The  virus  is  then  dropped  on  to  this 
area  and  well  rubbed  in  with  the  blunt  end  of  the  needle.  It  is  then 
allowed  to  dry  before  it  is  covered,  which  often  requires  twenty  minutes. 
A  method  of  vaccinating  much  in  vogue  of  late  consists  in  scraping  off 
the  surface  layers  of  the  skin  until  a  pink,  oozing  spot  is  obtained  without 
actual  bleeding.  The  vaccine  virus  is  well  rubl)e(l  in  and  allowed  to 
dry.  I  used  this  method  in  some  200  cases,  but  found  that  I  secured 
more  certain  results  by  the  older  method  of  scarifying. 

After  Care. — The  wound  should  be  covered  with  an  aseptic  bandage 
and  should  be  kept  covered  as  any  other  surgical  wound  would  be. 
Were  this  principle  universallv  carried  out  a  great  source  of  trouble 
after  vaccination  would  be  eliminated.  Serious  sores  are  caused  by 
extraneous  germs.    Their  introduction  may  result  from  lack  of  care  in 


VACCINIA 


551 


performing  the  operation,  but  more  often  from  improper  care  or  injury 
after  it  has  been  performed.  Infection  in  older  children  is  more  common 
when  vaccination  is  done  on  the  leg,  because  it  is  more  apt  to  be  infected 
with  dust.  Little  girls  who  are  vaccinated  on  the  leg  and  are  then 
allowed  to  run  about  with  the  sore  unprotected  are  particularly  liable 
to  develop  complications.  Such  complications  may  be  prevented  by  a 
protective  dressing.  A  heavy  surgical  dressing  is  not  advisable,  as 
it  sweats  and  softens  the  scab.  Shields  are  more  apt  to  cause  trouble 
than  to  prevent  it.  This  is  particularly  true  of  those  that  are  covered 
or  have  hard  edges.  Talcum  powder  should  be  freely  used,  particularly 
if  the  sore  is  moist.  A  light  gauze  bandage  which  is  changed  frequently 
is  the  best  dressing  when  it  does  not  stick  in  the  sore.  When  there  is 
considerable  soreness  or  the  dressing  sticks,  a  light  wire  shield  or  a 
perforated  felt  shield  of  large  size  is  admissible  and  often  gives  much 
comfort.  It  should  be  changed  or  cleansed  frequently.  A  few  turns 
of  light  gauze  bandage  should  be  placed  over  it. 

If  the  wound  becomes  infected  and  purulent  it  should  be  cleaned  out 
like  any  other  wound  and  dressed  surgically.  Poultices  and  oily  ap- 
plications should  not  be  used  after  vaccination.  In  fact,  as  long  as  the 
wound  is  pursuing  a  normal  course  no  application  should  be  made  to 
it.  Protection  is  all  that  it  requires.  If  it  becomes  too  moist  or  oozes 
serum,  it  may  be  dusted  with  bismuth  subgallate,  aristol,  or  some 
simple  dusting  powder. 

Selection  of  Lymph. — Bovine  lymph  is  now  used  almost  wholly  in 
this  country  and  should  be  employed  exclusively.  When  the  operation 
is  properly  performed,  the  danger  of  conveying  disease  is  completely 
removed,  which  is  not  true  of  humanized  virus.  Glycerinated  lymph 
should  be  selected  as  the  most  perfect  product  yet  devised.  Saprophytic 
germs  cannot  live  in  glycerin  in  hermetically  sealed  tubes.  When 
properly  prepared  such  lymph  is  sterile  and  cannot  be  contaminated 
in  handling,  as  so  often  happens  with  quill  and  ivory  points. 

Time  for  Vaccination. — Although  young  infants  bear  vaccination  well, 
as  a  rule,  for  reasons  already  referred  to,  it  is  unwise  to  vaccinate  during 
the  first  or  even  the  second  month.  In  well-nourished  healthy  infants 
the  third  month  is  the  best  time  for  vaccination.  They  are  usually  less 
ill  than  when  they  are  older,  and  complications  are  less  liable  to  occur 
than  during  the  first  weeks.  In  delicate  children  it  is  well  to  wait  until 
the  nutrition  is  fully  established  and  the  general  condition  assured. 
It  is  unwise,  unless  smallpox  is  prevalent,  to  vaccinate  when  the  child 
is  acutely  ill  or  is  suffering  from  any  active  disease  of  the  skin  or  lymph- 
atics, particularly  eczema  or  urticaria. 

Re  vaccination. — In  considering  this  subject,  it  is  wise  to  determine 
first  just  what  is  to  be  expected  from  vaccination.  For  this  purpose 
we  cannot  do  better  than  quote  the  words  of  Jenner,  whose  claims  for 
vaccination,  though  always  positive,  were  judicious  and  by  no  means 
extravagant.  His  own  words  were:  "Duly  and  efficiently  performed, 
it  will  protect  the  constitution  from  subsequent  attacks  of  smallpox  as 
much  as  that  disease  itself  will.    I  never  expected  that  it  would  do  more, 


552  INFECTIOUS  DISl'JASI'JS 

ami  it  will  not,  I  holieve,  do  less."  It  is  well  known  tliat  smallpox  is 
sometimes  repeated  in  the  same  subjeet,  that  is,  that  imnumity  is  not 
always  lifelong.  No  eompetent  authority  claims  that  the  immunity 
conferred  by  vaccination  is  always  lifelonj^.  In  many  cases  it  is  of 
limited  duration,  beinji;  sometimes  as  short  as  six  or  s(>ven  years.  In 
a  few  cases  one  vaccination  seems  to  aiford  lifelon<jj  innnunity,  and  in 
most  cases  two  successful  vaccinations  are  sufficient. 

Experience  of  more  than  a  century  has  streni^thened  and  confirmed 
the  teachings  of  .lenner.  Some  of  the  lessons  taught  by  this  experience 
may  be  sunnnari/A'd  as  follows:  1.  The  first  lesson  cannot  be  better 
stated  than  in  the  words  of  the  Berlin  Board  of  Health:  "Vaccination 
in  infancy,  renewed  at  the  end  of  childhood,  renders  an  individual 
practically  as  safe  from  death  from  smallpox  as  if  the  disease  had  been 
survived  in  childhood  and  almost  as  safe  from  attack."  2.  The  duration 
of  the  immunity  conferred  by  vaccination  is  varial)le.  In  many  indi- 
viduals vaccination  in  infancy  and  revaccination  in  childliood  is  sufficient 
for  life  protection.  In  a  limited  number  innnunity  is  lost  in  five  or  six 
years. 

It  is  never  possible  to  know  with  certainty  to  which  class  an 
individual  belongs.  In  the  face  of  an  epidemic,  therefore,  vaccination 
of  all  persons  who  have  not  been  vaccinated  w'ithin  five  or  six  years 
is  giving  what  the  lawyers  call  the  benefit  of  a  reasonable  doubt.  Every 
one  who  has  been  vaccinated  in  infancy  and  childhood  should  be 
vaccinated  not  less  than  once  in  adult  life.  3.  The  inumuiity  conferred 
by  vaccination  is  in  direct  proportion  to  the  thoroughness  with  which 
it  is  performed,  and  this  is  shown  with  considerable  accuracy  by  the 
character  and  number  of  the  resulting  scars.  4.  Vaccination  in  infancy 
alone  is  not  sufficient  to  prevent  smallpox  among  the  adult  population. 


SMALLPOX. 

Smallpox  or  Variola  is  an  acute,  infectious,  and  very  contagious  disease 
marked  by  a  pustular  eruption  and  a  fever  which  lasts  for  three  or  four 
days  and  is  followed  by  a  secondary  or  suppurative  fever  on  the  eighth 
or  ninth  day.  It  is  one  of  the  most  virulent  of  the  contagious  diseases, 
and  those  who  are  exposed,  if  unprotected  by  vaccination,  are  almost 
invariably  attacked.  Smallpox  has  appeared  in  nearly  every  country 
of  the  globe  and  is  of  very  ancient  date.  The  "great  plague"  described 
liy  (ialen  was  probably  smallpox.  Fiu'ther  facts  regarding  the  disease 
will  be  found  in  the  section  on  Vaccination. 

Etiology.  Exciting  Cause. — Until  very  recently  it  was  necessary  to 
write  of  smallpox  as  of  the  other  eruptive  fevers,  that  the.mic-ro-organism 
wa,s  unknown.  It  now  seems  probable  that  the  exciting  micro-organism 
of  the  disease  has  been  discovered.  Councilman  has  reported  the 
discovery  of  intracellular  and  intranuclear  bodies  in  the  lesions  of 
smallpox  which  are  probably  the  specific  cause  of  the  disease.  These 
bodies  are  protozoa,  the  cytorydeH  variola'  fCuarniori).    In  a  more  recent 


SMALLPOX  553 

communication  {The  Journal  of  Medical  Research,  February,  1904) 
Councilman  and  a  half-dozen  collaborators  present  evidence  which 
seems  to  confirm  the  belief  that  this  is  in  fact  the  micro-organism  of 
smallpox.  His  conclusions  are  summed  up  in  the  following  words: 
"In  the  early  stage  of  the  specific  lesions  of  the  skin  and  mucous  mem- 
branes in  smallpox,  bodies  are  found  which  vary  in  form,  structure, 
and  size.  We  regard  these  bodies  as  the  parasites  causing  the  disease. 
They  occur  within  the  epithelial  cells,  within  the  nuclei,  and  free. 
The  forms  within  the  nuclei  are  subsequent  to  those  which  develop 
within  the  cytoplasm.  They  are  present  in  the  greatest  number  in 
cases  of  the  greatest  severity  and  rapidity,  of  course.  They  do  not 
occur  as  isolated  structures,  but  one  form  follows  another  by  gradual 
transitions,  forming  a  cycle  which  corresponds  with  the  cycle  of  living 
things. 

"  In  the  different  cases  the  same  forms  are  found  at  the  same 
period  of  the  disease.  The  bodies  increase  rapidly  in  the  lesions,  and 
the  lesions  increase  in  extent  by  continuous  infection  of  adjoining 
epithelial  cells.  The  same  forms  are  found  in  corresponding  situations 
in  the  lesions  of  different  cases." 

It  is  impossible  to  cultivate  the  parasite  in  artificial  media  and  Koch's 
postulates  cannot,  therefore,  be  wholly  fulfilled.  Inoculation  experi- 
ments in  apes  are  very  conclusive,  for  those  animals  are  susceptible  to 
both  vaccinia  and  smallpox.  The  work  of  investigation  is  still  being 
pushed,  and  further  results  may  be  expected  in  the  near  future. 

Predisposing  Causes. — It  will  surprise  many  to  know  that  in  former 
times  smallpox  was  essentially  a  disease  of  childhood,  over  80  per  cent, 
of  all  cases  occurring  in  children  under  five  years.  As  vaccination  is 
done  chiefly  in  infancy  and  childhood,  it  is  a  strong  proof  of  its  efficacy 
that  the  occurrence  of  the  disease  has  been  transferred  from  infancy 
to  adult  life,  when  immunity  has  been  exhausted.  Susceptibility  is 
almost  universal,  there  being  but  few  cases  on  record  of  complete 
insusceptibility.  Unvaccinated  infants  and  young  children  are  particu- 
larly susceptible,  but  otherwise  age  and  sex  do  not  influence  its  trans- 
mission. Smallpox  is  most  prevalent  during  cold  weather.  Extensive 
epidemics  are  not  common  during  the  summer. 

Source  of  Infection.— SmaWpox  is  directly  contagious  and  may  be 
transmitted  by  intermediary  infection.  The  contagium  resides  in  the 
exhalations  from  the  lungs' and  skin,  in  various  secretions  and  excre- 
tions, and  in  the  pustules  and  dried  crusts.  The  crusts  dried  and 
pulverized  into  dust  may  transmit  the  disease  through  clothing  and 
bedding  to  great  distances  and  render  it  almost  impossible  to  completely 
disinfect  a  sick-room.  The  poison  of  smallpox  is,  in  fact,  the  most 
tenacious  and  persistent  of  all  the  infectious  diseases.  There  is  con- 
siderable evidence  to  show  that  aerial  transmission  is  possible  through 
a  radius  of  a  quarter  of  a  mile  and  perhaps  more. 

Period  of  Incubation. — The  most  common  period  is  twelve  days,  the 
extremes  being  eight  to  sixteen  days,  though  Osier  asserts  that  there 
are  authentic  cases  of  twenty  days'  incubation  period. 


554  INFECTIOUS  DISEASES    ' 

Period  of  Confagiousness. — Smallpox  is  j)n)l)al)l_v  contagious  from 
the  first  symptoms,  and  it  certainly  continues  so  until  the  last  crust  has 
fallen  anil  all  purulent  secretions  Juive  cea.sed.  The  period  of  isolation 
can  rarely  be  made  less  than  six  weeks. 

Clinical  Types. — Smallpox  presents  three  types:  the  ordinary  type 
(variola  vera),  which  may  he  discrete  or  confluent;  the  hemorrhagic 
type;  varioloid. 

Ordinary  Type. — This  type  runs  its  course  in  four  stages:  invasion, 
eruption,  desiccation,  and  desijuamation. 

In  children  the  onset  is  freciucntly  marked  by  a  convulsion  and  there 
mjiy  be  several  during  the  first  twenty-four  hours.  In  older  patients 
a  chill  is  the  first  symptom.  Vomiting  occurs  eai'ly  and  may  be  uuuiy 
times  repeated.  It  is  accompanied  by  frontal  and  lumbar  pain.  The 
temperature  rises  rapidly  and  may  reach  104°  F.  on  the  first  day.  The 
headache  and  backache  are  more  intense  than  in  any  other  iiifectious 
disease.  On  the  fourth  day  and  often  earlier  a  macular  eruption  appears 
on  the  forehead  and  soon  becomes  papular.  On  the  sixth  day  the 
papules  change  into  vesicles  filled  with  a  clear  fluid.  On  the  eighth  day 
the  vesicles  change  to  pustules  and  an  areola  forms.  The  pustules 
mature  by  the  tenth  day  and  soon  rupture,  begin  to  dry  and  form  crusts. 
Desiccation  goes  on  during  the  third  week  and  descjuamation  begins. 
The  crusts  sometimes  fall  rapidly,  but  in  other  cases  two  weeks  are 
required  to  complete  this  stage. 

As  the  rash  begins  to  appear  the  temperature  begins  to  fall,  but  does 
not  usually  reach  normal.  The  patient  feels  Ijetter  and  all  the  symptoms 
abate.  As  the  pustular  stage  begins  the  temperature  rises  as  high  and 
often  higher  than  did  the  primary  fever.  The  symptoms  return  and 
there  is  great  pain,  particularly  in  the  face,  which  is  swollen  so  as  to 
be  unrecognizable.  In  the  discrete  type  the  secondary  fever  often 
begins  to  subside  on  the  second  day  and  reaches  normal  after  ten  days. 
In  the  confluent  form  there  is  often  little  or  no  remission  after  the 
primary  fever,  but  remission  may  occur  even  in  severe  cases.  The 
fever  ranges  above  104°  F.  and  may  persist  through  the  third  week. 
At  the  height  of  the  pustular  stage  the  patient  presents  a  picture  not 
equalled  in  any  other  disease.  The  face  is  a  mass  of  ])ustules  and  if 
free  areas  are  left  they  are  inflamed  and  edematous.  In  fatal  cases 
death  occurs  about  the  twelfth  day.  In  other  cases  the  disease  subsides 
slowly,  rarely  by  crisis.  The  symptoms  gradually  ameliorate  and  con- 
valescence is  estal)lished  during  the  fourth  week. 

Hemorrhagic  Type. — "^Fhis  type  is  not  common  in  children.  It  occurs 
in  three  forms.  In  the  first  slight  hemorrhages  occur  in  the  vesicles, 
which  frecjuently  abort  and  the  disease  usually  runs  a  mild  and  short 
course.  In  the  second  hemorrhages  occur  in  the  pustules.  The  disease 
is  .severe  and  death  occurs,  as  a  rule,  between  the  seventh  and  ninth  days. 
Bleeding  from  the  mucous  surfaces  may  also  occur.  In  the  third  form, 
the  so-c-alled  purpura  variolosa,  a  hyperemic  eruption  appears  early, 
often  on  the  second  or  third  day,  and  frequently  becomes  hemorrhagic. 
Ecchymoses  appear  under  the  skin  and  conjunctiva^,  the  face  is  swollen, 


PLATE  XIX. 


Smallpox  in  the  Late  Pustular  and  Deslceative  Stage.  Arms 
and  hands  shoAA^  secondary  umbllieation  due  to  rupture  and 
central  collapse  of  pustules.    (Welch  and  Schamberg.) 


SMALLPOX  555 

and  hemorrhages  occur  from  the  mucous  surfaces.  Death  occurs  early, 
often  before  the  appearance  of  the  variolar  eruption.  It  is  to  this  form 
of  the  disease  to  which  the  name  of  black  smallpox  has  been  given. 

Varioloid. — That  form  of  modified  smallpox  which  sometimes  occurs 
in  those  who  have  been  vaccinated  some  time  before  is  known  as 
varioloid.  It  is  an  unfortunate  name,  for  it  has  sometimes  led  to  care- 
lessness in  the  isolation  and  care  of  patients.  Varioloid  is  not  simply 
a  disease  like  smallpox,  but  it  is  smallpox.  The  clinical  course  varies 
considerably.  Some  patients  are  but  slightly  ill;  others  are  seriously  so. 
Generally  the  attack  begins  suddenly  with  symptoms  common  to  the 
usual  type,  but  less  severe.  The  pain  in  the  back  and  head  may  be 
severe  and  the  temperature  may  go  to  103°  F.  The  eruption  is  scattered 
and  abortive  and  does  not  pass  through  the  full  pustular  stage.  The 
temperature  falls  promptly  and  there  is  no  secondary  fever.  The  chief 
difference  between  varioloid  and  the  ordinary  type  of  smallpox  is  that 
in  varioloid  there  is  no  pustular  stage  and  no  secondary  or  suppurative 
fever.  The  lesions  simply  come  out  as  papules  and  in  less  than  a  v/eek 
dry  into  warty  or  horny  bodies  which  leave  no  mark. 

Symptomatology.  Fever. — The  onset  of  the  initial  fever  is  usually 
sudden  and  the  temperature  ranges  high.  It  is  often  104°  F.  or  over 
on  the  first  day  and  may  go  to  105°  F.  on  the  second  and  106°  F.  or 
even  more  on  the  third.  It  falls  as  the  eruption  appears,  usually  on 
the  fourth  day.  The  secondary  fever  is  at  its  height  in  favorable  cases 
between  the  eighth  and  tenth  days.  It  is  at  first  somewhat  remittent, 
but,  as  the  case  progresses,  becomes  more  markedly  remittent  or  actually 
intermittent.  The  temperature  often  falls  gradually  to  normal  during 
the  third  week  of  the  disease,  but  this  is  sometimes  delayed  until  the 
foiu'th  week. 

Erwption. — An  initial  rash  sometimes  appears  during  the  stage  of 
invasion.  It  may  appear  in  a  macular  form  simulating  measles  or  as 
a  diffuse  erythema  simulating  scarlet  fever.  The  characteristic  eruption 
of  smallpox  appears  on  the  third  or  fourth  day.  It  is  seen  first  on  the 
forehead,  face,  wrists,  and  extremities,  but  in  infants  it  often  develops 
first  in  the  folds  of  the  skin,  especially  in  the  groin.  It  shows  first  as 
small,  red  spots,  macules,  of  pinhead  size,  looking  much  like  fleabites. 
On  the  fifth  day  these  spots  have  become  larger  and  darker  in  color; 
they  are  slightly  elevated  and  may  be  felt  with  the  finger  as  papules. 
The  papules  are  tender  and  often  the  seat  of  burning  pain.  After 
twenty-four  or  thirty-six  hours  more  the  papules  change  into  vesicles, 
each  showing  a  clear  summit  with  a  slight  depression,  the  so-called 
umbilication  (Fig.  122  and  Plate  XIX.).  By  the  eighth  day  the  vesicles 
have  become  turbid  and  globular  in  shape,  the  umbilication  having 
disappeared.  These  pustules  are  surrounded  by  a  red  areola  and  the 
adjacent  skin  is  swollen  and  edematous  and  becomes  painful.  In 
weak  and  poorly  nourished  children  the  papules  are  sometimes  pale  in 
color  and  show  very  little  areola.  As  the  pustular  stage  is  established 
the  itching  becomes  intense  and  the  patient,  unless  closely  watched, 
tears  his  skin.     ^Nhen  the  pustules  are  fully  formed  there  is  a  fetid, 


556  INFECTIOUS  DISEASES 

sic-klv  odor,  and  the  patient,  even  in  diserete  smallpox,  becomes  a  hideous 
object.  The  pustule  being  completed,  it  either  ruptures  and  discharges 
its  contents,  which  dries  into  a  yellowish  scab,  or  it  dries  down  into  a 
crust.  This  stage  of  desiccation  begins  on  the  face  usually  on  the  twelfth 
(lav  of  the  disease.  By  the  seventeenth  or  eighteenth  day  the  stage  of 
des(|uaination  is  established  and  the  crusts  begin  to  fall.  They  leave 
a  depression  stained  a  reddish-brown  color,  which  gradually  fad(>s 
after  five  or  six  weeks.  If  there  has  been  ulceration  or  a  pustule  lias 
broken  or  the  sore  has  been  deep  enough  to  involve  the  cutis,  a  white 
sj){)t  or  pit  is  formed.  The  face  slowly  loses  its  j)ur])le  color,  but  the 
pockmarks  are  permanent.  In  strictly  discrete  smallpox  pitting  is  rare. 
As  the  eruption  appears  on  the  skin  it  appears  also  on  the  hard 
palate  and  on  the  inside  of  the  cheeks,  and  sometimes  in  the  larynx 
and  trachea.  In  the  latter  locations  it  is  sometimes  the  cause  of  death 
iji   infants  through  associated  etlema.     The  eruption  on  the  raucous 

Vu..  122 


Swulliug  of  the  face  on  the  seventh  day  in  a  fatal  case  of  smallpox.    (Welch  and  Schamberg.) 


surfaces  pursues  a  different  course  from  that  on  the  skin.  Eacli  lesion 
iK'gins  as  a  papule  of  grayish  color  which  soon  ulcerates,  leaving  an 
excavated  sore  with  a  red  areola.  These  ulcers  are  usually  very  sensitive 
and  greatly  increase  the  suffering  of  the  patient.  Tiie  eruption  some- 
times ajjpears  on  the  conjunctiva,  leading  to  deep  ulceration,  followed 
l)y  a  permanent  scar  and  sometimes  by  destruction  of  the  eye.  The 
lymph  nodes  of  the  neck  are  always  more  or  less  swollen  when  the 
throat  is  involved. 

In  confluent  smallpox  the  lesions  are  close  together;  the  inflammation 
and  edema  of  the  skin  are  excessive;  as  the  pustular  stage  develops  the 
ace,  liands  and  feet  become  great  ulcers.  In  no  other  disease  does 
the  patient  become  so  transformed  in  appearance.  He  must  be  turned 
upon  a  sheet  an,  handh.l  with  rubber  gloves.  Even  in  the  most  severe 
conHuent  cases  the  eruption  remains  discrete  on  the  trunk.  Sydenham 
i><>mted  out  long  ago  that  the  condition  of  the  face  is  the  best  o-„ide 
to  the  severity  of  the  attack.    He  also  laid  down  th(>  rule  that  the  more 


SMALLPOX  557 

the  eruption  appears  before  the  fourth  day  the  more  Hable  it  is  to  become 
confluent.  The  crusts  in  severe  confluent  smallpox  are  very  slow  in 
falling,  a  full  month  occasionally  being  required.  In  severe  cases  the 
confluent  sores  may  be  covered  by  large  scabs  under  which  suppuration 
goes  on,  destroying  considerable  areas  of  true  skin.  When  these  large 
crusts  fall,  broad  scars  are  left  which  contract  and  may  cause  grave 
deformities. 

Constitutional  Symptoms. — In  addition  to  the  headache,  backache, 
fever,  and  vomiting,  which  have  already  been  referred  to,  there  are 
sore  throat,  pain  in  the  pharynx,  restlessness,  somnolence,  and  often 
delirium.  The  countenance  has  an  anxious  expression;  the  respirations 
are  frequent  and  labored;  the  pulse  is  bounding  and  there  is  throbbing 
of  the  carotids;  the  face  is  flushed  and  the  conjunctivae  are  congested; 
there  is  great  thirst.  The  spleen  is  enlarged  and  there  is  active  leuko- 
cytosis. Muscular  weakness  develops  with  extreme  rapidity.  In  severe 
cases  a  typhoid  condition  develops  and  the  patient  lies  in  a  low,  mutter- 
ing delirium,  with  brown,  dry  tongue  and  all  the  symptoms  of  extreme 
nervous  depression. 

Complications  and  Sequelae. — Unlike  many  diseases,  it  is  the  disease 
itself  that  is  to  be  feared  most  in  smallpox.  Though  febrile  albuminuria 
may  occur,  nephritis  is  rare;  this,  however  should  not  be  overlooked. 
The  only  common  complication  referable  to  the  digestive  system  is 
diarrhea,  which  is  of  most  frequent  occurrence  in  young  children. 
Ix)bar  pneumonia  is  rare,  but  bronchopneumonia  is  not  uncommon. 
It  is  usually  present  in  fatal  cases.  Salivation  is  rare  in  children.  It 
commonly  appears  about  the  fourth  day  and  lasts  but  three  or  four 
days.  Suppuration  in  the  joints  occurs  in  rare  cases.  On^hitis  and 
ovaritis  are  of  not  infrequent  occurrence,  but  are  usually  of  mild  type. 
Laryngitis  may  be  a  serious  complication.  The  accompanying  edema 
may  cause  fatal  occlusion  or  the  cartilages  may  be  involved  by  necrosis. 
Simple  conjunctivitis  is  common  in  the  early  stages  and  is  rarely  serious, 
but  the  purulent  conjunctivitis  of  the  later  stage  is  one  of  the  gravest 
complications  of  the  disease.  The  results  are  fortunately  less  serious 
now  than  they  formerly  were,  when  less  care  was  bestowed  upon  the 
eyes.  If  the  eyelids  are  kept  from  adhering  and  the  eyes  are  cleansed 
frequently,  excessive  keratitis  and  perforating  ulcers  of  the  cornea  can 
usually  be  averted.  Otitis  media  resulting  in  perforation  of  the  tympa- 
num and  otorrhea  may  prove  a  grave  complication  by  causing  deafness. 
Cellulitis  and  abscess  of  the  subcutaneous  connective  tissue  occasionally 
occur  as  well  as  local  gangrene,  and  boils  are  very  frequent  during 
convalescence.  Delirium  is  frequent  during  the  febrile  stage  and  post- 
febrile insanity  sometimes  occurs.  Various  forms  of  paralysis  may 
appear,  due  probably  to  peripheral  neuritis  like  that  of  diphtheria. 

Relapse  and  Recurrence. — A  peculiar  secondary  eruption  sometimes 
occurs  after  desquamation,  but  it  is  a  question  whether  it  is  a  true 
relapse  or  not.  Second  attacks  of  smallpox  are  by  no  means  unknown. 
Marson  saw  47  second  attacks  among  5982  smallpox  patients.  Haeser 
st^ites  that  in  Verona  24  cases  of  second  attack  were  observed  within 


558 


INFECT  10 1 'S  DISE.  I SES 


ten  years,  and  Ilcin  reports  57  ca^es  oec-urrinj,'  in  Wiirtemberg  between 
lS;3i  and  ISiil.    This  means  that  the  period  of  immunity  is  not  always 

lifelon<j;.  i     •      i       i 

Diagnosis.— The  diajifnosis  of  smallpox  cannot  be  made,  m  the  absence 
(if  known  exjiosure,  until  the  rash  has  begun  to  appear  and  can  often 
be  made  with  certainty  only  on  the  second  or  third  day  of  the  rash. 
Tiie  initial  iieadache,  "backache,  and  fel)rilc  symptoms  should  put  the 
practitioner  on  his  guard,  and  he  should  isolate  every  suspicious  case. 
The  eruption  on  the  first  day  is  not  characteristic  and  rarely  becomes 
so  before  the  second  day.  The  presence  of  an  initial  rash  has  frequently 
led  to  error,  a  diagnosis  of  scarlet  fever  or  of  measles  having  been 
made.  In  typical  cases  doubt  need  not  exist  after  the  second  day  of 
the  rash  if  due  consideration  is  given  to  all  the  symptoms.  As  in  all 
eruptive  fevers,  the  diagnosis  should  not  be  made  from  the  rash  alone, 
but  from  the  case  as  a  whole.  It  is  the  cases  of  varioloid  and  mild 
smallpox,  like  those  of  the  epidemic  of  1900  and  1901,  that  lead  to 
trouble.  Such  cases  present  some  very  difficuU  problems  for  (liagnosis. 
The  diagnosis  between  meningitis  and  smallpox  is  often  difficult  and 
sometimes  impossible  before  the  rash  appears.  The  pain  in  head  and 
back,  vomiting,  fever,  and  photophobia  may  occur  in  either.  'As  a 
rule,  the  face  hi  smallpox  is  flushed,  while  in  meningitis  it  is  apt  to  be 
pale  and  the  fever  does  not  range  as  high.  Pustular  syphilides  may 
be  mistaken  for  variolar  pustules  and  pustular  glanders  may  also  be 
mistaken  for  smallpox.  The  disease  most  likely  to  be  mistaken  for 
smalljiox  is,  without  doubt,  chickenpox.  The  differential  diagnosis 
between  these  two  diseases  is  considered  under  Chickenpox. 

Prognosis. — The  statement  is  frequently  made  that  smallpox  has 
become  a  much  milder  disease  than  it  formerly  was,  and  that  vacci- 
nation, therefore,  is  less  necessary.  Facts  certainly  do  not  bear  out 
this  statement.  It  is  quite  true  that  during  the  recent  epidemic  the 
death  rate  has  been  low.  It  is  true  of  all  epidemic  diseases  that  the 
prevailing  type  varies  considerably  in  different  years,  and  smallpox  has 
certainly  not  shown  itself  of  late  in  some  localities  in  its  most  virulent 
forms.  Among  those  who  have  never  been  vaccinated  the  disease  in 
most  (>pi(lemics  is  almost,  if  not  quite,  as  dangerous  as  it  ever  has  been. 
In  the  I/)nd()n  Smallpox  Hospital,  between  1775  and  1800,  all  patients 
of  course  being  unvaccinated,  the  mortality  rate  was  32.5  per  cent. 
In  1853  Marsden  found  that  the  rate  for  the  previous  sixteen  years  was 
35.55  per  cent,  of  unvaccinated.  In  a  recent  study  of  smallpox  Welch 
reports  1512  cases  in  unvaccinated  persons,  with  a  death  rate  of  over 
58  per  cent.  In  young  children  the  rate  was  much  higher  than  this. 
Hart  gives  the  death  rate  of  unvaccinated  patients  as  fully  40  per  cent. 
In  the  Sheffield  epidemic  of  1887,  the  death  rate  was  54.2  per  cent.  It 
is  certain  that  a  death  rate  of  over  50  per  cent,  is  not  abnormal  for 
smallpox,  including  all  ages  and  types. 

The  amount  of  eruption  is  the  most  important  guide  to  prognosis; 
the  greater  the  amount,  the  more  grave  the  prognosis.  Age  is  also  an 
important  factor.     The  mortality  is  very  high  in  young  children  and 


SMALLPOX  559 

also  in  the  aged.  It  is  usually  fatal  under  two  years.  Osier  says  that 
among  3164  deaths  from  smallpox  in  Montreal,  2717  were  in  children 
under  ten  years.  Hemorrhagic  smallpox  is  very  fatal.  The  disease 
is  especially  fatal  in  the  intemperate  and  debilitated.  "Very  high  fever 
with  delirium  and  subsultus  are  symptoms  of  ill  omen."  Death  may 
occur  in  any  stage.  In  malignant  cases  it  sometimes  occurs  before  the 
rash  has  developed.  It  sometimes  occurs  in  children  at  the  beginning 
of  the  suppurative  stage,  but  is  more  common  during  the  second  week. 
It  may  then  be  due  to  complications,  but  is  commonly  due  to  exhaustion. 

Prophylaxis. — One  method  of  prevention  is  so  pre-eminent  above  all 
others  that  it  must  receive  chief  attention.  That  method  is  vacci7iation. 
It  is  not  only  sufficient  for  preventing  the  occurrence  of  the  disease  in 
the  individual,  but  if  universally  carried  out  in  a  community  eradicates 
it.  In  view  of  the  fact,  however,  that  there  is  always  in  this  country  a 
considerable  number  of  individuals  who  for  one  reason  or  another  have 
not  been  vaccinated,  the  most  stringent  methods  of  isolation  and  dis- 
infection should  be  enforced.  The  health  officials  are  abundantly 
justified  in  forcibly  removing  smallpox  patients  to  public  hospitals 
where  isolation  can  be  made  complete.  Failure  to  promptly  notify  the 
health  authorities  of  its  appearance  should  be  punished  by  heavy 
penalties.  Where  the  disease  does  appear,  the  directions  given  for  the 
management  of  scarlet  fever  should  be  enforced  with  the  greatest 
thoroughness,  and  fumigation  should  be  done  with  more  than  the  usual 
care.  Every  city,  in  fact  every  community  of  any  size,  should  have 
properly  equipped  hospitals  for  the  treatment  of  smallpox,  so  arranged 
that  they  can  be  extended  to  accommodate  the  unusual  numbers  that 
they  may  be  required  to  receive  during  an  epidemic. 

Treatment. — Treatment  during  the  stage  of  incubation  of  smallpox 
is  a  question  of  very  great  interest,  for  it  is  possible  to  prevent  the 
disease  by  vaccination  if  it  is  performed  promptly.  Welch,  of  Phil- 
adelphia, has  had  large  experience  in  this  direction  and  asserts  that 
while  no  inflexible  rule  can  be  laid  down,  yet  it  may  be  said  that  if 
vaccination  is  performed  on  the  first  or  second  day  after  exposure, 
protection  may  be  perfect,  and  if  performed  between  the  second  and 
fifth  days  it  may  be  partial.  In  vaccinia  the  areola  appears  between 
the  seventh  and  eighth  days  and  the  sore  is  at  its  height  on  the  ninth 
or  tenth  day.  The  incubation  of  smallpox  is  eleven  or  twelve  days, 
and  the  eruption  does  not  appear  until  the  third  or  fourth  day.  Hence, 
the  vaccinia  has  full  opportunity  to  do  its  work.  Welch  bases  his 
views  on  194  cases  of  vaccination  done  during  the  incubation  stage  of 
smallpox.  The  accompanying  chart  (Fig.  123)  demonstrates  more 
clearly  how  the  prevention  of  smallpox  is  possible  by  vaccination  on 
the  first  day  or  two  of  the  stage  of  incubation. 

In  the  interval  between  the  onset  and  beginning  of  the  eruption, 
treatment  is  quite  difl^erent  from  that  required  after  the  first  week. 
Before  the  eruption  begins  to  appear  the  treatment  should  be  that  of 
all  severe  febrile  states.  The  fever  is  best  controlled  by  the  cold  pack 
or  the  cold  bath  at  70°  F.    The  severe  pains  can  be  relieved  by  nothing 


500 


INFECTIOUS  DISEASES 


l)iit  ()|)iiitcs,  iind  tliry  should  In-  ,<,M\vn  without  liesitation.  Counter- 
irritation,  and  csjM'cially  nuistard  pastes,  should  he  ahsohitdy  prohibited, 
for  the  eruption  is  liai)le  to  heeonie  eonfiuent  upon  irritated  surfaces. 
The  use  of  bismuth,  lime-water,  and  similar  remedies  may  sometimes 
mitin;ate  the  vomiting,  especially  in  children,  but  they  are  usually  less 
eti'ective  than  the  swallowin*,'  of  small  pieces  of  ice.  The  convulsions, 
delirium,  and  other  nervous  symptoms  may  be  relieved  somewhat  by  the 
use  of  bromide  of  sodium  or  potassium,  or  by  chloral  given  by  the 
rectum.  Water  may  be  given  freely.  The  diet  suggested  for  scarlet 
fever  mav  be  appropriately  used  during  the  febrile  stage  of  smallpox. 


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Chart  showing  the  temperature  range  in  typical  ca,ses  of  smallpox,  inoculated  smallpox  and  vac- 
cinia, and  showing  also  the  relative  course  pursued  by  those  diseases.  Vaccinia  being  short  in  its 
invasion  and  course,  active  virus  can  be  obtained  from  the  pock  on  the  fourth  day  and  its  immuniz- 
ing power  is  developed  before  the  invasion  period  of  smallpox  is  complete.— J?n7js/i  Medical  Journal. 

In  the  later  stages  the  appetite  often  improves  and  the  stomach  becomes 
more  tolerant  of  food,  so  that  the  question  of  feeding  is  often  not  difficult 
even  in  quite  .severe  cases.  The  tendency  to  overheat  the  patient  is 
as  .strong  in  smallpox  as  in  the  other  eruptive  fevers  and  should  be 
strenuously  combated.  The  temperature  of  the  room  should  not  be 
over  70°  F.,  and  it  should  be  w^ell  ventilated  and  the  bedding  should 
be  light. 

As  the  eruption  begins  to  appear  the  fever  subsides  and  tlie  patient 
becomes  more  comfortable,  .so  that  many  of  the  measures  before  taken 
may  be  droj)j)e(i.  Symptoms  mu.st  be  treated  as  they  arLse.  The  throat 
now  usually  requires  attention.    Bland  washes,  boric  acid  solution,  etc., 


SMALLPOX  561 

should  be  used  and  the  mouth  and  throat  should  be  kept  as  clean  as 
possible  without  producing  irritation.  As  the  eruption  develops,  the 
burning  of  the  skin  demands  attention;  2  per  cent,  carbolized  vaselin 
or  a  2  per  cent,  ichthyol  ointment  may  give  relief.  In  some  cases  cool 
wet  dressings  may  be  more  effective.  As  the  eruption  develops  in  the 
thick  skin  of  the  hands  and  feet  it  often  gives  great  pain,  which  may 
be  relieved  by  the  application  of  ice-cold  compresses.  In  some  cases 
prolonged  baths  of  the  hands  and  feet  in  lukewarm  water  are  more 
comforting  to  the  patient.  Very  hot,  wet,  flannel  bandages  may  even 
be  used. 

As  the  stage  of  suppuration  begins  the  treatment  must  be  again 
changed.  Fever  returns  and  the  patient  must  face  the  dangers  of 
suppuration.  The  physician  must,  therefore,  give  his  attention  to  the 
fever.  He  must  attempt  to  disinfect  the  purulent  exudation,  relieve 
the  throat  symptoms,  and  sustain  the  vital  strength  of  the  patient, 
for  death  from  exhaustion  is  to  be  feared.  The  cold  bath  during  this 
stage  is  difficult  to  administer  and  does  not  have  the  beneficial  effect 
seen  in  many  febrile  conditions.  During  the  pustular  stage  the  itching 
is  often  intolerable.  Scratching  breaks  the  pustules,  whose  contents 
decompose  and  not  only  become  offensive  but  poison  the  patient. 
Antiseptic  treatment,  therefore,  is  very  important.  Welch  especially 
commends  a  mixture  of  olive  oil  and  lime-water  15  c.c.  (|-oz.)  and  carbolic 
acid  0.65  to  1  c.c.  (10-15  ^,).  Oil  of  eucal_yptus  may  be  used  in  place  of 
the  carbolic  acid.  A  great  number  of  remedies  have  been  proposed  with 
the  greatest  assurance  as  capable  of  preventing  pitting  and  disfiguring 
of  the  face.  Both  Welch  and  Osier,  men  of  great  experience,  assert 
that  not  one  has  stood  the  test  of  extended  use.  No  treatment  can 
wholly  prevent  disfigurement  in  severe  confluent  cases.  Any  measure 
which  will  check  or  limit  the  depth  of  the  inflammation  will  by  so  much 
limit  the  pitting.  Some  advantage  is  gained  by  protecting  the  face  and 
hands  from  the  light  and  air.  Among  the  most  eflficient  measures  of 
treatment  is  the  application  of  absorbent  gauze  soaked  in  cold  water. 
Antiseptics  may  be  added,  of  which  carbolic  acid  is  one  of  the  best. 
The  gauze  may  be  cut  into  the  form  of  a  mask  and  should  be  removed 
as  it  becomes  soiled.  Crusts,  when  they  begin  to  appear,  should  be  kept 
softened  with  glycerin  or  cold  cream.  Later  in  the  disease  frequent 
baths  are  advantageous. 

The  eyes  require  treatment  as  soon  as  the  lids  begin  to  swell.  When 
they  show  a  tendency  to  become  glued  together,  they  should  be  separated 
every  two  or  three  hours  and  gently  but  thoroughly  cleansed  with  boric 
acid  solution  or  other  mild  wash.  Constant  care  in  keeping  them  open 
and  cleansed  will  do  much  toward  preventing  blindness.  Obstruction 
of  the  larynx  should  be  watched,  and,  in  extreme  cases,  tracheotomy 
should  be  performed.  Diarrhea  is  best  treated  by  some  preparation 
of  opium,  especially  paregoric.  little  or  nothing  can  be  done  for 
internal  hemorrhage.  Throughout  this  whole  stage  the  strength  of 
the  patient  should  be  supported.  Stimulants  and  concentrated  nourish- 
ment should  be  begun  in  all  the  graver  cases  as  suppuration  begins, 
36 


562  INFECTIOUS  DISEASES 

and  should  lx«  pushed  to  their  limit  lus  soon  as  sigus  of  exhaustion 
heeonie  apparent.  The  nourishment  should  he  given  at  short  intervals 
and  in  (luantitics  which  the  stomach  can  tolerate.  Welch  gives  not 
less  than  two  cpiarts  of  milk  each  day  in  which  two  to  four  eggs  are 
beaten,  and  he  frequently  administers  six  to  twelve  ounces  of  whiskey. 
Digitalis  and  strychnine  in  full  doses  may  also  he  required. 

During  convalescence  falling  of  the  crusts  may  he  hastened  by  a 
dailv  warm  bath  with  carbolizcd  soap.  The  patient  should  not  be 
considered  safe  until  every  crust  has  fallen  and  all  su])piirating  dis- 
charges have  ceased.  The  tonic  and  stimulating  tn>atment  should  be 
continued  and  a  nutritious  diet  should  be  prescribed. 


CHAPTER   XXII. 

CONGENITAL  SYPHILIS— RHEUMATISM. 

CONGENITAL  SYPHILIS. 

By  GEORGE  M.  TUTTLE,  M.D. 

Acquired  Syphilis,  either  in  infancy  or  before  the  age  of  puberty, 
is  a  rarity.  Of  course  cases  do  occur  from  time  to  time,  being  inoculated 
accidentally,  as  a  rule,  but  from  a  clinical  standpoint  they  are  in  no 
respects  different  from  syphilis  as  it  occurs  in  adult  life,  and,  hence, 
really  need  no  separate  description. 

There  is  a  form  of  syjshilis,  however,  peculiar  to  infancy  and  child- 
hood, differing  in  many  respects  from  the  acquired  disease,  and  merit- 
ing careful  consideration  in  every  way.  This  is  the  inherited  form  of 
the  disease,  or,  as  it  is  ordinarily  called.  Hereditary  or  Congenital  Sj^hilis. 
The  terms  are  used  rather  promiscuously,  or  at  least  synonymously, 
to  express  the  fact  that  the  infection  with  the  disease  has  taken  place 
some  time  during  either  embryonic  or  fetal  life,  or  it  may  even  be  in 
the  time  before  the  union  of  the  ovum  and  spermatozoon. 

There  is  little  doubt  that  syphilis  is  an  infectious  disease  of'  rather 
chronic  nature,  but  as  yet  attempts  to  isolate  a  specific  germ  of  the 
infection  have  been  in  vain.  A  number  of  micro-organisms  have  been 
isolated  from  syphilitic  lesions  by  different  observers,  but  no  one  of 
them  has  been  accepted  as  the  specific  agent.  One  difficulty  has  been 
the  impossibility  of  inoculating  the  disease  on  any  animal,  but  within 
a  very  few  months  two  different  observers  have  announced  the  successful 
inoculation  of  the  chimpanzee  with  syphilitic  virus,  and  this  observation 
may  lead  to  the  settlement  of  the  disputed  point  by  convicting  one 
of  these  organisms  or  some  as  yet  undescribed  organism  as  the  specific 
cause  of  syphilis. 

Etiology. — Congenital  syphilis  may  arise  from  infection  through  the 
spermatozoon,  from  the  ovum  itself,  or  from  both  coincidently,  or  sub- 
sequently to  conception  from  the  maternal  tissues.  A  few  cases  of 
infection  during  the  act  of  parturition  have  been  reported,  but  these 
would  scarcely  come  under  the  head  of  congenital  syphilis.  There  can 
.  be  no  doubt  but  that  the  spermatozoa  of  a  syphilitic  father  may  convey 
syphilis  to  his  future  child.  After  the  union  of  spermatozoon  and  ovum 
a  father  subsequently  syphilitic  can  only  infect  an  embryo  indirectly 
through  the  medium  of  the  mother. 

(563) 


5(54  i.\F/:cTinrs  diseases 

On  the  other  liaiid,  i)  uiDthor's  possibilities  for  eonveying  syphilis 
begin  with  the  germinal  period,  the  unimpregnated  ovum  itself  being 
syj)hilized,  and  continue  through  the  embrvonie  and  fetal  periods  of 
tiie  intrauterine  existence  even  to  the  time  of  birtii.  Of  course,  in  case 
of  sypliiHs  in  both  parents  the  chances  of  the  fetus  being  syphilitic 
are  doubled. 

If  a  woman  contract  syphilis  while  pregnant,  she  may,  but  probably 
will  not,  convey  the  disease  to  her  offspring.  The  later  in  pregnancy 
the  infection  occurs,  the  less  is  the  liability  of  fetal  inoculation;  but, 
clinically,  the  majority  of  cases  escape  the  disease  no  matter  what  time 
it  occurs,  showing  that  the  placenta  acts  as  a  protector  to  the  fetus 
as  well  as  the  mother.  This  is  not  a  universal  law,  but  it  holds  good 
in  most  cases. 

The  father  may  inoculate  a  healthy  ovimi  with  a  syphilitic  sperm- 
atozofin,  and  a  syphilitic  child  may  be  born  of  this  conception,  the 
mother,  however,  escaping  the  disease  entirely;  but  she  does  acquire 
syphilis  in  a  modified  form  as  the  result  of  having  harbored  a  syphilitic 
fetus  for  nine  months  in  her  uterus.  This  is  proven  by  the  fact  that 
she  is  able  to  suckle  a  child  with  syphilitic  stomatitis  without  herself 
developing  th(>  disease,  while  another  woman  would  be  infected.  This 
is  the  soH'alled  "Colics'  law."  Some  authorities  insist  that  such  immu- 
nity on  the  part  of  the  mother  can  only  have  been  acquired  by  her 
having  had  syphilis  in  a  form  so  mild  as  to  have  escaped  observation. 
Others,  among  whom  may  be  named  the  great  Joseph  O'Dwyer,  have 
questioned  the  existence  of  any  immunity  on  the  part  of  a  woman  bear- 
ing a  syphilitic  child.  O'Dwyer  used  to  state  emphatically  that  a  child 
born  syphilitic  coukl  infect  its  mother  if  she  were  healthy,  and  would 
forbid  the  nursing  of  the  sy])hilitic  child  either  by  its  own  mother  or  by 
any  other  woman  on  that  ground. 

Parents  in  the  secondary  or  active  stage  of  syphilis  at  the  time  of 
impregnation  are  almost  certain  to  transmit  the  disease  to  their  off- 
spring; if  in  the  tertiary  stage,  or  where  conception  occurs  after  pro- 
longed and  proper  antisyphilitic  treatment,  the  danger  of  transmission 
is  very  slight. 

Pathology. — The  lesions  of  congenital  syphilis  may  not  be  at  all 
<haracteristic,  but  in  the  various  viscera,  and  in  the  bones  and  skin  it 
is  common  to  find  some  rather  typical  changes,  all  of  w^hich  partake, 
in  a  general  way,  of  the  nature  of  hyperplasias  of  the  connective-tissue 
elements. 

As  \yould  be  naturally  expected,  since  the  placental  blood  enters  the 
fetal  circulation  by  way  of  the  liver,  the  commonest  visceral  changes 
are  found  in  this  organ.  The  liver  is  usually,  luit  not  always,  enlarged. 
There  may  be  present  in  it  rather  widespread  round-cell  infihration 
and  general  proliferation  of  the  interlobular  connective  tissue.  These 
fibroid  h>^3erplasias  follow  in  a  general  way  the  course  of  the  smaller 
arteries.  Accompanying  this  is  a  degeneration  of  the  parenchymatous 
cells.  In  many  such  livers  there  are  visible  to  the  naked  eye  small, 
scattered,  yellowish-white  spots,  the  size  of  pinheads,  giving \he  liver 


COXGEXITAL   SYPHILIS  565 

a  speckled  appearance.  These  may  be  considered  miliary  gummata. 
The  spleen  is  regularly  enlarged,  and  the  connective  tissue  being  in 
excess,  the  spleen  is  harder  and  tougher  than  normal. 

The  lungs  may  show  fibroid  changes  similar  to  those  seen  in  the 
liver.  There  is  an  increase  in  the  connective-tissue  elements,  without 
much  or  any  change  in  the  epithelium.  Such  lungs  have  a  whitish 
color,  and  are  tougher  and  less  elastic  in  consistency  than  normal. 

Even  the  kidneys  may  show  evidences  of  some  connective-tissue 
hyperplasia,  with  resulting  parenchymatous  degeneration,  but  such 
kidneys  are  in  nowise  characteristic  of  syphilis,  and  are  found  in  other 
secondary  conditions. 

The  lymph  nodes  may  also  present  a  moderate  degree  of  small-cell 
proliferation,  but  are  not  characteristically  invaded  by  the  disease. 

The  osseous  changes  are  more  typical,  and  are  more  regularly  present 
than  many  of  the  visceral  lesions.  There  are  ordinarily  evidences  of 
inflammatory  changes  at  the  junction  of  the  shafts  and  epiphyses. 
These  are  commonest  in  the  long  bones,  as  the  femur,  tibia,  humerus, 
or  radius,  but  are  quite  frequent  in  the  metacarpals,  metatarsals,  or 
phalanges,  producing  here  the  condition  commonly  called  s^'philitic 
dactylitis.  In  the  milder  cases,  the  medullary  spaces  are  irregularly 
formed  and  the  lime-salts  consequently  deposited  in  an  at^-pical  manner. 
In  more  marked  cases  the  microscope  shows  real  inflammation,  with 
reddish  or  yellowish  spots  of  osteomyelitis  and  proliferation  of  cartilage 
cells.  This  causes  some  enlargement  and  swelling  of  the  epiphyseal 
junction,  and  in  advanced  cases  we  now  and  then  find  separation  of 
epiphysis  and  diaphysis.  These  inflammatory  processes  may  be  confined 
to  the  neighborhood  of  one  joint  only,  or  may  be  seen  coincidently  in 
different  bones. 

In  late  cases  we  find  osteoph^iic  gro\^ihs  on  the  shafts  of  the  long 
bones,  due  to  a  chronic  proliferative  periostitis,  with  the  production  of 
new  bone  under  the  periosteum.  This  leads  to  great  thickening  and 
enlargement  and  deformity  of  the  affected  bones,  and  is  rather  char- 
acteristically seen  in  the  tibife.  Gummata  may  also  form  in  the  bones, 
and  may  break  down  and  ulcerate  just  as  in  the  tertiary  form  of  acc|uired 
syphilis. 

The  skin  rarely  shows  lesions  commensurate  with  the  clinical  im- 
portance of  the  manifestations  appearing  in  it.  In  most  fatal  cases 
the  eruptions  have  disappeared  and  the  skin  shows  nothing  character- 
istic. If  only  an  erythematous  eruption  has  been  present,  nothing  can 
be  seen  after  death.  On  the  other  hand,  we  may  see  superficial  erosions 
from  bullous  or  pustular  eruptions,  or  there  may  be  distinct  ulceration, 
especially  about  the  anus  or  the  mouth  (Fig.  124).  Microscopically, 
in  the  simpler  forms  of  eruption  we  find  simple  round-cell  infiltration, 
especially  about  the  principal  vessels  and  the  glandular  apparatus;  in 
the  ulcerative  or  pustular  processes  there  will  be  more  or  less  destruction 
of  the  epidermal  layers  of  the  skin. 

Symptomatology. — The  condition  of  the  child  at  birth  depends  on 
two  main  factors,  the  virulence  of  the  infection  which  it  has  inherited 


566 


INFECTIOUS  DISEASES 


and  the  stage  of  tlie  disease  in  which  it  is  horn.  For  instance,  the 
infection  Is  so  overwhchiiing  in  one  fetus  that  it  never  comes  to  maturity, 
but  miscarriage  takes  place  at  some  period  of  intrauterme  existence. 
On  the  other  hand,  many  infants,  the  subject  of  congenital  syphilis, 
are  born  to  all  api)earances  entirely  normal,  and  only  show  mild  evidences 
of  the  disrasi-  after  a  considcralAe  time.  Between  these  two  extremes 
all  degrees  of  develoi^ment  of  symptoms  are  seen. 

It  must  Ih>  remembered  that  "in  congenital  syphilis  there  is  no  initial 
lesion  to  correspond  with  the  chancre  of  the  accjuired  disease,  the 
infection  having  taken  place  through  the  fetal  circulation,  and  that 
the  period  of  incubation  is  of  an  indcHnite  length  of  time.  Possii)ly 
the  change  of  environment  from  a  warm,  Huid  medium  to  a  compara- 
tively cool,  gaseous  one,  which  the  skin  and  mucous  membranes  undergo 
at  birth,  is'^the  exciting  cause  for  the  outbreak  of  symptoms.     At  any 

Fig.  124 


InfJEintile  syphilis ;  eruption  and  fissures  of  mouth.    (GottheU.) 

rate  the  average  infant  the  victim  of  congenital  syphilis  is  born  normal, 
and  the  most  careful  inspection  will  fail  to  find  any  sign  of  the  presence 
of  the  disease.  The  real  evidences  of  the  disease  begin  in  a  very  large 
percentage  of  the  cases  during  the  second,  third,  and  fourth  weeks  of 
postnatal  life.    Occasionally  they  are  postponed  until  the  second  month. 

Accordingly  the  clinical  history  of  congenital  syphilis  may  be:  mis- 
carriage during  the  early  months  of  pregnancy;  the  birtli,  prematurely 
or  at  term,  of  a  dead  fetus  showing  undoubted  lesions  of  inherited 
s^'philis  in  its  skin,  bones,  and  viscera;  rarely  the  birth  of  a  living  infant 
in  the  eruptive  .stage  of  the  disease,  showing  lesions  of  the  skin  and 
mucous  membranes;  but  usually,  if  the  pregnancy  go  to  term,  a  living 
child  showing  no  evidences  of  .syphilis. 

Our  consideration  of  the  subject  do^-s  not  include  the  study  of  the 
first  two  varieties — stillborn  infants. 

In  cases  born  with  the  disease  fully  developed    we  find    a  decided 


CONGENITAL   SYPHILIS  567 

degree  of  malnutrition  present.  The  infant  is  emaciated,  its  skin 
wrinkled,  and  its  appearance  that  of  senility.  Skin  eruptions  are  the 
most  characteristic  evidences  of  the  disease.  Vesicular  eruptions  seem 
the  most  common,  and  these  are  regularly  seen  on  the  palms  and  soles 
as  a  palmar  or  plantar  pemphigus.  The  vesicles  may  contain  purulent 
serum,  and  may  have  burst,  leaving  a  loose  torn  skin  hanging,  attached 
at  the  edge.  In  other  places  they  may  dry  up  and  form  yellow  crusts 
on  various  parts  of  the  body.  A  coryza  may  be  present  at  birth,  and 
the  mucous  membrane  of  the  lips  may  be  shiny  and  dry,  and  tend  to 
crack.  These  infants  are  regularly  very  feeble,  and  usually  live  but  a 
short  time. 

In  the  ordinary  case  of  the  birth  of  a  normal-appearing  infant,  the 
clinical  history  is  quite  different.  On  close  inspection  such  an  infant 
will  .show  a  clean  skin  and  normal  mucous  membranes,  but  there  is 
often  a  little  anemia  present,  which  if  watched  gradually  increases. 
Some  of  these  infants  are  liable  to  suffer  from  hemorrhages  at  the 
umbilicus,  and  the  cord  is  often  friable.  The  infant  may  become 
wakeful  and  its  nutrition  begin  to  fail;  but  the  first  characteristic  sign 
that  shows  itself  is  a  persistent  coryza,  due  to  mucous  patches,  that 
appears  about  the  third  week — the  so-called  "snuffles."  The  nasal  dis- 
charge may  be  profuse  or  only  moderate ;  it  may  be  thin  and  watery,  or 
at  times  a  little  blood  stained,  but  it  does  not  respond  to  the  ordinary 
means  that  are  used  to  cure  such  discharges.  Accompanying  this  con- 
dition the  infant's  cry  may  be  hoarse,  and  inspection  may  show  mucous 
patches  in  the  mouth  and  throat.  The  lips  may  be  fissured  more  or 
less,  producing  rhagades  (Fig.  124),  which  leave  the  tell-tale,  radiating 
scars  of  later  life  (Fig.  125). 

Almost  coincident  with  these  lesions  in  the  nasal  and  oral  mucous 
membranes  appear  the  typical  cutaneous  manifestations  of  the  disease. 
As  in  the  acquired  disease,  the  skin  lesions  are  multiform  and  may 
present  a  variety  of  lesions  at  the  same  time.  Thus  we  may  see  a 
simple  erythema  or  roseola  at  one  time,  or  macules,  papules,  vesicles, 
or  even  pustules  at  another. 

The  most  common  eruption  is  the  maculopapular  syphilide.  The 
infiltration  in  the  skin  may  be  almost  nil  when  only  macules  are  present, 
while  at  other  times  or  in  other  places  it  may  be  rather  extensive,  caus- 
ing decided  thickening  and  a  resultant  papular  condition.  The  macules 
and  papules  show  a  decided  tendency  to  coalesce,  producing  a  continuous 
eruption  in  places,  while  the  outlying  areas  present  normal  skin  between 
the  individual  lesions.  These  confluent  rashes  seem  to  be  distributed 
especially  where  the  irritation  is  greatest,  and  are  frequent  about  the 
buttocks  and  genitals,  and  generally  extend  down  the  thighs  on  to  the 
calves  and  on  to  the  feet  (Fig.  126).  The  face  is  another  common 
situation  for  these  macular  eruptions. 

The  margins  of  the  continuous  eruptions  are  irregular,  and  often 
separated  by  clear  skin  from  scattered  laut  smaller  patches  of  the  same 
kind  of  rash.  The  edges  are  usually  but  slightly  raised  above  the  level 
of  the  sound  skin,  but  may  be  decidedly  infiltrated  and  thickened. 


568 


INFECTIOUS  DISEASES 


The  opitlu'liuni  may  in  y^lacos  peel  off  and  leave  ragged  edges,  this  being 
seen  oftenest  about  the  feet  and  hands.  In  the  early  stages  these  macules 
and  papules  ar(>  bright  red,  but  as  they  grow  older  they  grow  duller  in 
color  and  finally  become  copper  or  ham  colored,  which  is  considered 
rather  ty])ical  oF  syphilitic  rashes. 

Vesicular  syphilides  are  rare,  but  may  occui'.  On  the  palms  and 
soles  they  produce  the  well-known  ])emphigus.  The  vesicles  vary  in 
size  from  a  ])ea  to  the  larger  bulhc.  which  may  cover  a  good-sized  area 


Fig.  125 


Results  of  congenital  syphilis,  showing  scars  around  the  mouth.    (Stowell.) 


of  skin.  They  contain  more  or  less  serum,  which  may  be  reddish  in 
color.  On  rupturing,  the  underlying  skin  is  seen  to  be  infiltrated  and 
copper  colored. 

Pustular  eruptions  are  common  and  are  often  mixed  in  with  the 
maculopapular  rashes.  They  occur  mostly  on  the  face,  head,  and 
buttocks,  I  Hit  may  appear  anywhere.  They  often  come  in  groups  about 
the  forehead  or  near  the  anus.  On  discharging  their  contents  dirty 
crusts  are  formed.     Very  probably  the  pustules  are  most  frequently 


CONGENITAL  SYPHILIS 


569 


due  to   infection  of    pre-existing  syphilitic    rashes   by  pus-producing 
organisms. 

Alopecia  is  ordinarily  present  to  a  greater  or  less  degree,  but  is  scarcely 
characteristic,  as  it  occurs  in  so  many  forms  of  malnutrition.  This  may 
involve  the  eyelashes  and  eyebrows,  as  well  as  the  scalp.     The  nails 


Fig.  126 


Case  of  congenital  syphilis.    (Gottheil.) 


may  show  signs  of  inflammation  at  their  junction  with  the  skin,  and 
if  the  matrix  is  involved  the  nail  may  be  shed. 

The  mucocutaneous  junctions  are  usually  the  seat  of  lesions.  Those 
of  the  lips  have  been  already  described.  The  anal  orifice  often  shows 
mucous  patches,  ulcerations,  fissures,  or  condylomata,  depending  on 
the  severity  of  the  individual  lesion.  The  same  is  true  of  the  vulvar 
orifice  (Fig.  127). 

As  in  most  bone  diseases  occurring  during  growth,  those  of  syphilis 


o70 


IXFECTIOUS  DISEASES 


i\K  also  commonest  al)out  the  epiphyseal  junctions.  The  s^Tuptoms  are 
pain,  tenderness,  and  swellinfj:,  bnt  very  little  redness.  Resulting  from 
these  chantrt\s,  the  joint  is  more  or  less  voluntarily  imniohilized,  as  move- 
ment incnniscs  the  pain,  and  a  pseudoparalysis  may  be  produced,  for 
which  often  these  babies  are  brought   to  the   physician.     Pseudopar- 

alvsis  may  occur  without  separa- 


Fi.:.  1:7 


tion  of  the  ejMphysis.  The  bones 
of  the  u])per  or  lower  extremities 
are  most  likely  to  be  involved, 
such  as  the  humerus  or  femur, 
but  any  bones  may  l)e  attacked, 
e\en  the  clavicles  or  the  ribs. 

Syphilitic  epiphyshis  may  occur 
singly  or  l)e  multiple,  and  is  often 
quite  difficult  to  distinguish  from 
tluit  due  to  rickets  or  tuberculosis. 
Often  only  treatment  will  settle 
the  diagnosis.  The  epiphysis  may 
separate  from  the  shaft,  but  the 
skin  is  seldom  involved  and  sinuses 
are  rare.  The  neighboring  joints 
usually  escape  involvement,  al- 
though a  secondary  arthritis,  prob- 
alily  due  to  some  pus-producing 
organism,  may  occur  as  a  com- 
plication. S^-yjhilitic  dactylitis  in- 
volving the  phalanges  and  meta- 
carpals or  metatarsals  may  occur, 
and  is  very  similar  to  the  condi- 
tion produced  by  tid>erculosis. 
Here  we  often  find  necrosis  and 
sinuses  resulting  from  the  extru- 
sion of  dead  pieces  of  lx)ne.  Peri- 
ostitis of  the  proliferative  variety  may  occur,  causing  thickening  in  the 
shafts  of  the  long  bones,  and  often  the  formation  of  nodes  on  the  flat 
Ixines,  such  as  the  frontal  or  parietal  bones — the  so-<."alled  cranial  bosses. 
These  may  rarely  suppurate. 

On  examining  the  abdomen  of  infants  presenting  any  or  all  of  the 
alKive  signs,  we  regularly  will  find  the  liver  and  spleen  palpable  well 
l)elow  their  usual  location  and  distinctly  enlarged.  The  edges  of  both 
will  l)e  clean  cut  and  give  the  impression  of  hardness.  Except  in  the 
presence  of  some  skin  or  lx)ne  lesion  draining  into  the  neighboring 
lymph  nodes,  the  nodes  will  not  l)e  found  so  uniformly  and  generally 
enlarged  lis  they  are  in  the  acquired  disease. 

Gummata  may  develop  anywhere  in  the  body.  In  the  skin,  if  un- 
treated, they  break  down  and  form  ulcers.  In  the  mucous  membranes, 
as  those  of  the  nose  and  mouth,  they  regularly  invade  the  bone,  and  as 
they  ulcerate  they  may  perforate  the  nasal  septum  or  the  hard  ])alate, 


\M 


»«^^^ 


Infantile  syphilis ;  large  area  of  condylomata  on 
buttocks.    (Gottheil.) 


CONGENITAL  SYPHILIS  571 

or  may  cause  necrosis  of  the  nasal  bones.  These  perforations  of  the 
nasal  septum  or  roof  of  the  mouth  are  quite  t}^ical.  When  invohang 
the  nasal  bones  they  lead  to  the  deformity  known  as  saddle-back  nose, 
a  distinct  depression  at  the  junction  of  the  nasal  and  cartilaginous 
portions.  Gummata  may  likewise  occur  in  the  viscera,  but  are  ordinarily 
not  diagnosed  in  these  locations.  In  some  late  cases  paresis  of  one 
extremity  with  symptoms  simulating  lead  palsy — e.  g.,  drop-wrist- — may 
develop- 

Anemia  and  all  the  evidences  of  malnutrition  graduallv  increase 
during  the  course  of  the  development  of  the  symptoms,  and  from  time 
to  time  an  irregular  fever  may  be  present. 

The  child  may  die  of  wasting,  or  of  some  intercurrent  disease,  but  if 
the  infection  is  mild,  and  if  proper  and  energetic  treatment  is  pursued, 
the  evidences  of  the  disease,  the  secondaries,  as  they  really  are,  gradually 
disappear  and  the  child  may  completely  recover. 

One  of  the  results  of  an  early  keratitis  is  a  corneal  opacity.  The 
permanent  teeth  often  present  rather  a  characteristic  appearance,  the 
so-called  "Hutchinson's  teeth"  (Fig.  128).  In  this  condition  the  upper 
central  incisors  are  deeply  notched  by  a  crescentic  depression  in  their 
cutting  edge,  the  enamel  is  imperfect,  and  the  teeth  themselves  are 
shaped  like  a  peg  and  rounded.  The  ear  having  been  involved,  a 
chronic  otitis  of  the  inner  ear  develops,  causing  a  loss  of  conducting 
power  in  the  auditory  nerve.  The  stigmata  which  follow  early  syphilis, 
interstitial  keratitis,  pegged  and  notched  teeth,  and  deafness,  are  some- 
times called  Hutchinson's  triad,  and  are  considered  quite  pathogno- 
monic. The  most  important  of  these  signs  are  the  so-called  Hutchin- 
sonian  teeth. 

Diagnosis. — In  case  of  stillborn  infants  the  presence  of  bullte  and 
the  examination  of  the  viscera  usually  will  clear  the  diagnosis.  Macer- 
ation must  not  be  considered  a  syphilitic  symptom. 

In  living  infants  a  well-marked  case  presents  few  difficulties.  The 
parental  history  must  be  taken  into  consideration,  particularly  the 
results  of  previous  pregnancies  of  the  mother.  Repeated  abortions 
and  the  subsequent  birth  of  a  living  child  presenting  some  signs  of  tlie 
disease  are  suspicious  circumstantial  evidence. 

An  incurable  coryza,  fissures  about  the  mucocutaneous  regions, 
epiphysitis,  multiform  rashes,  condylomata,  and  malnutrition  are  all 
valuable  signs.  Enlarged  spleen  and  liver  are  confirmatory.  Rachitis 
presents  a  number  of  these  same  signs,  but  it  must  be  remembered  that 
syphilis  produces  its  effects  usually  during  the  first  half  of  the  first 
year  of  life,  while  rickets  shows  most  plainly  during  the  latter  half  of 
the  first  year  and  the  first  half  of  the  second.  In  other  words,  rickets 
takes  time  to  develop,  while  congenital  syphilis  begins  to  present  s^Tup- 
toms  soon  after  birth. 

Hutchinson's  triad,  or  any  two  of  the  three  signs,  are  very  t}^ical. 
The  bony  lesions  are  very  difficult  to  separate  from  similar  changes 
due  to  tuberculosis.  Often  only  a  therapeutic  test  will  decide  the 
question.     Deformities  of  the  nose  and  hard  palate  are  always  aids, 


=  -o  IXFECTIOUS  DISEASES 

and  likewise  thickeninj,^  and  deformities  of  the  tibiae.  Paralysis 
due  to  syphilis  is  not  syninietrical  and  will  yield  to  specific  treat- 
ment. . 

Prognosis.— This  is  a  nuuh  more  fatal  disease  than  acquired  syplnhs 
of  adult  life.  Malnutrition  is  a  frequent  cause  of  death,  and  the  lowered 
vitality  due  to  this  cause  makes  such  infants  very  su.sceptihle  to  other 
diseases;  they  often  die  of  complications  that  a  normal  infant  would 
survive. '  The  earlier  after  birth  the  symptoms  develop  the  worse  the 


Fic;.  128 


•   Hutchinson's  teeth.    (Stowell.) 

prognosis,  and  naturally  the  earlier  and  more  vifrorous  the  treatment 
the  l^etter  the  chances  for  survival. 

Even  if  they  escape  death  through  a  mild  infection,  or  as  the  result 
of  active  treatment,  children  the  victims  of  this  disease  never  seem  to 
develop  entirely  normally.  They  show  evidences  of  malnutrition  of 
one  kind  or  another,  and  they  often  develop  rickets.  Their  gro\\'th 
may  be  .stunted,  their  mentality  may  never  l)e  all  that  it  should,  and 
finally  we  often,  even  after  mo.st  careful  treatment,  see  .some  of  the  late 


CONGENITAL   SYPHILIS  573 

signs  of  the  disease  developing  about  puberty.  So  that  in  no  way  can 
the  prognosis  be  looked  on  as  other  than  unfortunate. 

Treatment. — If  a  woman  known  to  be  syphilitic  should  become 
pregnant,  or  if  a  woman  should  be  pregnant  by  a  man  known  to  be 
syphilitic,  antisyphilitic  treatment  should  be  begun  as  early  in  pregnancy 
as  practicable,  and  should  be  continued  until  the  beginning  of  labor. 
This  treatment  should  be  the  ordinarily  accepted  one  by  mercury  or 
iodide  of  potassium,  or  both  combined,  according  to  the  indications  for 
the  individual  case.  If  a  child  is  born  to  such  a  mother,  every  elfort 
should  be  made  to  aid  natural  breast  feeding,  as  breast-fed  children 
always  do  better  than  hand-fed  ones  when  subject  to  this  disease. 
During  lactation  the  antisyphilitic  treatment  of  the  mother  should  be 
continued  whether  she  seems  to  need  it  or  not.  No  wet-nurse  should 
ever  be  employed  for  a  syphilitic  infant. 

Immediately  on  making  a  diagnosis  of  congenital  syphilis  mercurial 
treatment  must  be  begun.  It  may  be  administered  through  the  skin  by 
inunction,  or  by  way  of  the  stomach.  It  is  often  wise  to  use  first  one 
method  for  a  time  and  then  to  change  for  a  period  to  the  other.  Children 
bear  mercury  well  and  seldom  suffer  from  salivation,  but  their  bowels 
easily  become  loose,  and  this  is  always  an  indication  for  the  use  of  the 
inunction  method. 

For  inunction  the  ordinary  blue  ointment,  unguentum  hydrargyri, 
is  used  in  daily  dose  of  about  1.3  gm.  (a  scruple).  The  location  for 
rubbing  the  mercury  in  should  be  changed  from  day  to  day  to  avoid  irri- 
tating the  skin.  The  soles  of  the  feet,  the  skin  of  the  thighs  or  upper 
arms,  and  the  surface  of  the  back  or  abdomen  can  be  used  one  after  the 
other,  or  it  may  be  put  under  the  binder.  This  method  is  sure,  but 
dirty  and  troublesome.  The  oleate  of  mercury  from  0.5  to  5  per  cent, 
strength  is  sometimes  useful  and  it  is  a  cleaner  preparation  than  the 
blue  ointment.     Resorbin  is  a  good  vehicle  for  mercury. 

The  best  preparation  for  internal  use  seems  to  be  "gray  powder," 
hydrargyrum  cum  creta.  The  chalk  serves  to  counteract  slightly  the 
laxative  tendency  of  the  mercury.  It  should  be  given  in  doses  of  0.065  gm. 
(1  gr.)  three  times  a  day.  As  the  child  grows  older,  or  in  the  cases  of 
severe  infection,  0.130  gm.  (2  gr.)  three  times  a  day  may  be  given.  Some 
physicians  give  calomel  in  0.0065  gm.  (^  gr.)  doses  three  times  daily; 
others  the  corrosive  chloride  in  0.00108  gm.  (^  gr.)  doses  three  times 
daily;  and  others  the  protiodide,  hydrargyrum  iodidum  viride,  in  0.0162 
gm.  (j  gr.)  doses  three  times  a  day.  AVith  any  of  these  preparations 
for  internal  use,  in  case  of  diarrhea,  a  little  opium  may  be  combined, 
as  Dover's  powder  in  0.0162  gm.  (j  gr). 

I^ocally,  fissures,  ulcers,  and  condylomata  should  be  treated  by  dusting 
with  dry  calomel  powder,  or  by  the  application  of  calomel  ointment,  in 
the  proportion  of  4  gm.  (1  dr.)  to  30  gm.  (1  oz.)  of  vaselin.  In 
severe  skin  lesions  a  daily  bath  in  1  :  20,000  solution  of  corrosive 
sublimate  may  be  valuable.  "Snuffles"  is  treated  by  cleansing  the  nose 
with  a  mild  alkaline  wash,  as  Seller's  solution,  and  then  smearing  the 
inside  of  the  nostrils  with  unguentum  hydrargyri  ammoniati,  or  the 


574  INFECTIorS  DISEASES 

caloinrl  oiiiliiuMit  Later  treatment  will  require  iodide  of  potash  in  the 
saturated  sohition,  dose,  O.OO  c.c.  to  3  c.c.  (1  to  5  drops)  three  times  daily. 

Treatment  should  he  eontiniied  without  interruption  until  all  signs 
of  the  disea.se  have  disappeared,  including  enlarged  liver  and  spleen. 
Aft(>r  that  iuterruptions  ran  l)e  made  in  it  from  time  to  time,  with  re- 
lu'wai  of  the  treatmeut  again  for  the  two  to  three  years  that  are  ordina- 
rilv  looked  on  as  the  proper  length  for  eontiiuiing  in  the  acquired  disease. 

"Everything  possihle  in  a  hygienic  way  should  he  done  for  these 
infants':  regular  hours  for  eating  and  sleeping,  ahundance  of  fresh  air, 
scrupulous  cleanliness,  and,  in  case  the  mother  cannot  nurse  her  infant, 
careful  attcution  to  all  the  special  rules  for  scientific  artificial  feeding. 
An  iron  tonic  may  be  of  great  value  as  an  aid. 


RHEUMATISM. 

By  JOHN  RUHR  AH,  M.D. 

Rheumatism  is  an  acute,  non-contagious  fever,  the  exact  cause  of 
which  is  as  yet  unknown.  In  childreu  over  ten  years  of  age  it  is  char- 
acterized fre(|uently  l)y  the  same  symptoms  as  are  seen  in  adults:  fever, 
nniltiple  arthritis,  great  pain,  a  tendency  to  involvement  of  the  fibrous 
tissues,  and  of  inflammations  of  the  heart,  and  sour  sweating.  In 
children  between  five  and  ten,  and  even  younger,  typical  attacks  of 
articular  rheumatism  may  occur,  but  atypical  attacks  are  much  more 
connnon.  lender  five  years  articular  rheumatism  of  the  adult  type  is 
very  rare  and  the  disease  is  manifested  by  a  number  of  symptoms  no 
one  of  which  can  be  regarded  as  pathognomonic,  but  which,  taken 
together,  form  a  symptom-complex  that  makes  the  diagnosis  possil)le. 

The  variations  of  the  disease  as  seen  in  infants  and  young  childrcMi 
make  it  liable  to  be  mistaken  for  other  diseases,  while,  on  the  other 
hand,  totally  different  affections  are  called  rheumatic. 

Etiology. — The  exact  cause  of  the  disease  is  unknown,  but  there  are 
numerous  theories.    Three  of  these  may  be  mentioned: 

1.  That  rheumatism  is  an  infectious  disease.  This  is  borne  out  by  a 
study  of  the  occurrence  of  the  disease.  It  may  be  seen  in  epidemics 
and  these  epidemics  are  liable  to  be  followed  by  outbreaks  of  less 
severity.  It  occurs,  of  course,  apart  from  any  epidemic.  Poynton  and 
Paine,  Triboulet  and  Wassermann  have  independently  isolated  adiplo- 
cocc-us,  nearly  identical  in  each  instance,  which  they  regard  as  the  cause 
of  the  disease,  but  this  is  not  yet  confirmed.  The  infection  theory,  while 
not  definitely  proven,  is  generally  accepted. 

2.  That  the  disease  is  due  to  chemical  or  metabolic  causes.  This  is 
based  on  the  irleathat  there  Is  defective  assimilation,  with  the  formation 
of  abnormal  products,  which  are  toxic.  Lactic  acid  is  the  most  fre- 
quently mentioned  of  these. 

.3.  That  the  <lisease  has  a  nervous  origin. 

Pathology. — There  are  no  characteristic  postmortem  changes.  The 
joints  when  affected  are  swollen,  the  swelling  affecting  the  synovial 


RHEUMATISM  575 

membranes  and  ligaments  and  the  surrounding  tissues.  There  is  hyper- 
emia and  a  not  very  abundant  effusion  which  is  somewhat  turbid  and 
contains  leukocytes  and  some  flakes  of  fibrin.  The  pleurisy  and  pneu- 
monia which  are  frequently  found  are  due  to  other  organisms  and  there 
is  nothing  distinctive  in  the  lesions.  Changes  in  the  heart  are  men- 
tioned on  p.  695. 

Occurrence. — The  disease  is  most  frequently  found  in  the  temperate 
climates  where  the  humidity  is  high.  It  affects  girls  somewhat  more 
frequently  than  boys.  This  sex  difference  lasts  until  about  twenty  years 
of  age.  It  has  been  thought  by  many  to  be  an  hereditary  disease.  It 
certainly  seems  to  occur  in  families,  but  whether  that  is  due  to  trans- 
mission of  a  tendency  to  have  the  disease  or  whether,  as  may  be  probable, 
it  is  due  to  house  infection  or  to  house  occurrence  cannot  be  definitely 
stated.  It  is  quite  certain  that  exposure  to  cold  and  wet  predisposes  one 
to  an  attack.  One  attack  does  not  produce  an  immunity,  but  rather 
predisposes  to  a  second. 

Symptomatology. — The  adult  type  is  usually  seen  in  children  from 
about  ten  years  of  age.  The  older  the  child  the  more  hable  the  disease 
is  to  conform  to  the  adult  type,  and  the  younger  he  is  the  farther  the 
symptoms  will  deviate  from  it.  In  the  younger  cases  there  are  several 
marked  differences.  Not  many  joints  are  involved.  The  pain  is  not  so 
severe,  nor  the  fever  so  high ;  the  sweating  is  not  marked  and  has  little  or 
none  of  the  characteristic  sour  smell  as  observed  in  adults.  Instead  of 
lasting  three  weelcs  or  more  the  attack  is  usually  over  in  two  weeks  or  even 
a  few  days.     Relapses  are  uncommon  just  as  recurrences  are  frequent. 

In  acute  cases  in  children  the  onset  is  usually  sudden,  with  no  pro- 
dromes. There  is  more  or  less  pain  in  one  or  more  of  the  joints;  there 
is  fever,  which  is  ordinarily  not  very  high  and  may  only  be  100°  or 
101.5°  F.,  although  it  may  reach-  105°  F.  There  may,  however,  be  a 
gradual  onset,  with  vague  pains  in  several  joints;  an  indefinite  condi- 
tion of  malaise,  with  or  without  some  of  the  other  manifestations  of 
the  disease.  Usually  these  cases,  sooner  or  later,  show  more  or  less 
marked  symptoms  of  a  definite  attack.  A  rarer  mode  of  onset  and  one 
which  may  be  very  puzzling  is  to  have  fever,  headache,  and  some  gastric 
disturbance  for  several  days  before  there  is  any  pain.  There  may  be 
a  tonsillitis  at  the  outset,  or,  after  a  day  or  two  of  indefinite  symptoms, 
heart  murmurs  may  be  made  out. 

The  joints  most  usually  affected  are  the  knee,  ankle,  small  joints  of 
the  foot  and  the  wrist,  but  no  joint  can  be  said  to  be  exempt.  The 
joints  may  be  swollen  without  much  pain,  and  if  in  the  upper  extremity 
may  be  overlooked.  The  pain  may  not  be  severe  enough  to  keep  the 
patient  in  bed  or  it  may  be  as  severe  as  in  the  adult  type  of  the  disease. 

The  symptoms  persist  for  varying  lengths  of  time.  In  some  cases  of 
rheumatism  the  patient  is  all  right  in  from  five  to  seven  days;  the 
average  case  lasts  about  two  weeks,  while  some  may  drag  along  and 
tend  to  become  subacute  or  chronic. 

In  children  under  seven,  attacks  of  articular  rheumatism  are  rare, 
but  other  manifestations  may  be  found.     Under  three  rheumatism  is 


576  ISFECTIOVS  DISEASES 

rare,  l)iit  it  lias  Ih-cmi  ()l)sorvc(l  vxru  under  one  year  of  age.  In  these 
yoiin<,'  children  the  s\vellin<:j  of  the  joints  may  he  slif];ht  and  transient, 
with  little  or  no  heat  or  redness.  In  younger  children,  and  in  the  older 
ones  as  well,  the  symptom-complex  is  made  up  of  a  number  of  things, 
and  these  are  seen  in  divers  combinations,  and  sometimes  one  symp- 
tom is  prominent  and  sometimes  another.  The  course  is  extremely 
variable.     In  acute  cases,  however,  it  is  liable  to  be  about  two  weeks. 

Heart  Lesions. — These  are  described  in  detail  in  the  section  on 
Diseases  of  the  Heart,  but  the  subject  warrants  the  following  brief 
mention.  Involvement  of  the  heart  is  a  fre(|ucnt  occurrence  in  rheum- 
atism in  children.  It  is  said  to  be  more  liable  to  occur  in  them  than  in 
adults.  There  is  either  an  endocarditis,  a  pericarditis,  or  a  myocarditis, 
(See  p.  695.)  In  all  cases  of  suspected  rheumatism  the  heart 
should  be  carefully  studied  each  time  the  patient  is  seen.  It  is  a 
notorious  fact  that  acute  pericarditis  and  endocarditis  are  very  fre- 
(juently  overlooked.  When  found  in  the  course  of  a  febrile  disease 
of  obscure  nature,  with  some  of  the  symptoms  as  outlined  below,  it  is 
quite  safe  to  assume  that  it  is  rheumatic  and  the  child  should  be  treated 
accordingly.  In  most  cases  of  chronic  cardiac  disease  in  children  there 
is  a  history  of  rheiunatism  or  of  vague  joint  or  muscle  pains  which  may 
not  have  been  correctly  diagnosed  when  observed. 

Chorea. — This  is  another  frecjuent  manifestation  of  the  disease.  The 
relation  of  chorea  and  rheumatism  is  discussed  in  the  chapter  on  Chorea. 
It  usually  comes  on  after  an  attack  of  rheumatism.  In  about  half  the 
cases  of  chorea  there  is  a  history  of  rheumatism.  Sometimes  it  may 
precede  the  other  symptoms  of  the  disease.  In  still  others  the  child  is 
choreic  and  when  articular  symptoms  appear  the  chorea  gets  better  to 
recur  on  the  subsidence  of  the  joint  trouble. 

Tonsillitis  is  frequently  associated  with  rheumatism.  This  applies 
to  all  forms  of  tonsillitis  and  to  pharyngitis.  An  acute  attack  of  rheu- 
matism may  begin  with  tonsillitis.  Frecjuent  attacks  of  tonsillitis  in  a 
child  should  always  be  regarded  with  suspicion ;  and  if  there  is  associated 
heart  lesions  or  other  manifestations  of  rheumatism,  there  can  be  but 
little  doul)t  as  to  the  nature  of  the  throat  trouble. 

Skin  lesions  occurring  in  the  course  of  rheumatism  may  be  regarded 
as  a  part  of  the  disease.  These  are  so  varied  that  they  are  most  easily 
described  as  erythema  multiforme.  Sudamina  are  common.  There 
may  be  erythematous  rashes  not  unlike  a  scarlatina  rash.  Red  miliary 
ra-shes  are  frequently  seen.  Er\1;hema  nodosum  is  also  met  with.  In 
this  latter  affection  there  are  a  number  of  nodules  from  the  size  of  a 
bean  to  a  pigeon's  egg,  mostly  over  the  anterior  part  of  the  leg  and 
particularly  over  the  tibia,  but  occurring  on  the  face  and  other  parts 
of  the  body  as  well.  These  are  at  first  red  and  then  change  to  a  purple 
or  bluish  color  like  a  bruise.  They  are  tender  and  painful.  Their 
duration  is  about  two  or  three  weeks.  Purpura  is  not  quite  so  frequent 
in  children  as  in  adults,  but  is  met  with.  There  are  severe  forms  of 
purpura  described  under  the  name  of  peliosis  rheumatica  where  there 
is  fever,  swelling  of  the  joints,  bleeding  from  the  gums  and  mucous 


RHEUMATISM 


b71 


membranes  and  enlarged  spleen.  There  is  a  reasonable  doubt  as  to 
whether  these  are  really  rheumatic  or  not. 

Subcutaneous  nodules  were  described  by  Barlow  and  Warner.  They 
are  more  common  in  England  than  in  this  country,  but  are  met  with 
here  and  their  rarity  may  be  in  part  explained  by  the  fact  that  we  are 
not  so  in  the  habit  of  looking  for  them  as  they  are  abroad.  They  are 
of  considerable  diagnostic  value  when  they  are  present.  (In  England 
they  are  found  in  about  20  per  cent,  of  the  cases.)  They  consist  of 
small  transitory  nodules  which  have  been  described  as  fibrous,  and  they 
feel  like  it,  but  are  really  only  a  transient  infiltration  of  the  tissue.  They 
vary  in  size  from  a  pinhead  to  a  split  pea,  and  are  found  over  the  bones 
which  are  covered  only  with  skin  and  subcutaneous  tissue,  about  the 
joints,  and  along  the  course  of  the  tendons.  They  are  found  especially 
on  the  hands  and  wrists,  on  the  olecranon,  about  the  patella  and  the 
malleoli,  along  the  spine  of  the  scapula,  and  on  the  vertebrae.  While 
somewhat  difficult  to  see,  the  nodules  may  be  easily  felt.  They  come 
and  go,  remaining  weeks  or  months.  They  are  neither  painful  nor,  as 
a  rule,  tender.  They  are  more  frequent  in  children  than  in  adults. 
They  may  come  on  early  in  the  disease  or  about  the  time  the  patient 
is  getting  well,  or  they  may  come  on  without  any  acute  symptoms. 
They  are  even  associated  with  heart  lesions.  Similar  or  nearly  similar 
nodules  are  found  in  arthritis  deformans,  gout,  and  migraine. 

Pleurisy  and  pneumonia  are  both  frequently  met  with  in  the  course 
of  rheumatism,  but  may  be  regarded  as  true  complications,  being  due 
to  mixed  infections. 

Nervous  syviptoms  are  common  in  rheumatic  children.  Even  if  there 
is  no  chorea,  there  is  liable  to  be  a  nervous  condition — a  sort  of  hyper- 
sensibility.  The  children  start  at  noises,  make  nervous,  purposeless 
movements,  grimaces,  and  the  like.  They  are  also  prone  to  headaches 
and  to  nightmare.  Delirium  or  even  coma  may  be  met  with  in  the 
severe  forms  of  the  disease.  Meningitis  of  rheumatic  origin  has  been 
described,  as  has  also  neuritis. 

Anemia. — Almost  all  children  who  have  had  rheumatism  have  a  more 
or  less  severe  grade  of  secondary  anemia.  This  follows  so  regularly 
that  anemia  has  been  included  as  one  of  the  features  of  the  disease. 

Muscular  rheumatism  undoubtedly  occurs  in  children,  although  some 
have  stated  that  it  is  rare.  The  growing  pains  so  frequently  complained 
of  may  in  part  be  explained  in  this  way.  A  child  with  "growing  pains" 
should  be  examined  carefully  for  other  manifestations  of  rheumatism. 
A  form  most  frequently  seen  attacks  the  muscles  of  the  neck  producing 
torticollis.  In  these  cases  there  may  be  more  or  less  fever,  following  a 
rather  sudden  onset.  The  muscle  is  tender  to  the  touch  and  usually 
very  painful.  The  muscle  is  in  a  state  of  contraction  and  the  patient 
either  cannot  or  will  not  move  it.  The  symptoms  are  less  severe  when 
the  patient  is  in  bed.  The  head  may  be  twisted  to  one  side  or  be  re- 
tracted according  to  the  muscles  affected.  These  cases  may  roughly 
simulate  a  meningitis,  but  the  diagnosis  is  usually  easy.  They  may 
also  be  mistaken  for  caries  of  the  spine  and  the  diagnosis  be  rather 
37 


57S  ISFFA'TIorS   DISEASES 

difficult;  the  duration  of  tlie  disease  clears  up  the  case  wl.ere  tluMV  is 
any  (loui)t.  The  muscles  of  the  lei^s  are  next  frcciuently  affected  and 
almost  any  group  of  muscles  may  suller.  The  duration  is  usually  about 
a  week,  but  some  of  the  cases  may  last  much  longer.  There  is  fre- 
quently associated  tonsillitis  and  heart  lesions. 

Diagnosis. — The  diagnosis  of  rheumatism  in  infants  and  children 
is  not  always  an  easy  matter.  True  rluMUuatism  is  frequently  over- 
looked and  what  is  called  rheumatism  is  often  some  other  affection,  and 
vice  versa.  It  is  important  to  make  a  correct  diagnosis  as  the  future 
welfare,  the  life  itself  even  at  times,  may  depend  upon  it.  This  is  true 
where  infected,  suppurating  joints  are  mistaken  for  it  and  also  in  the 
case  of  scurvy. 

The  symptom-complex  as  described  al)ove  must  be  borne  in  mind. 
In  doubtful  cases  much  can  be  inferred  from  the  family  history  and 
the  previous  history  of  the  child.  The  previous  occurrence  of  skin 
lesions,  of  tonsillitis,  or  of  joint  or  muscle  pains  all  have  some  weight 
in  deciding  the  cpiestion.  The  presence  of  these  or  of  a  heart  lesion  is 
of  the  greatest  importance. 

Acute  rheumatism  must  be  differentiated  from  the  following  diseases : 

Scuri'i/,  many  cases  of  which  are  called  rheumatism.  The  infrecjuency 
of  rheumatism  during  the  first  two  years  of  life,  and  the  comparative 
frequency  of  scurvy  in  artificially  fed  children  should  arouse  a  sus- 
picion of  the  latter  disease  where  there  are  obscure  joint  pains  in  an 
infant.  The  nature  of  the  food  of  the  child,  the  presence  of  swelling 
or  bletnling  of  the  gums,  the  subperiosteal  hemorrhages  giving  rise  to 
large  swellings  about  the  long  bones,  and  the  absence  of  fever  are  all 
valuable  points.  The  hemorrhages  into  the  skin  in  scurvy  are  apt  to 
be  spots  from  half  an  inch  to  two  inches  in  diameter  and  look  more 
like  bruises  than  do  the  purpuric  spots  of  rheumatism.  They  are  also 
usually  near  or  about  the  larger  joints.  It  must  be  borne  in  mind 
that  scurvy  luay  occur  without  gum  lesions  or  hemorrhages;  in  fact, 
any  part  of  the  symptom-complex  may  be  wanting.  AVhen  in  doubt  a 
proper  diet  and  orange-juice  will  clear  up  the  diagnosis  in  most  cases 
in  a  few  days. 

Rickrfs  may  be  easily  mistaken  for  rheiuuatism.  The  restlessness, 
sweating  about  the  head,  throwing  off  the  covers  at  night,  rickety 
rosary,  craniotabes  and  the  nature  of  the  feeding  will  generally  prove 
sufficient  to  differentiate  the  two  diseases. 

Multiple  secondary  arthritis  occurs  after  a  mmiber  of  diseases  among 
which  gonorrhea,  dysentery,  scarlet  fever,  and  cerebrospinal  fever  are 
the  most  important.  In  infants  and  young  children  the  gonorrheal 
form  may  be  met  with  as  well  as  in  later  life.  Clement  Lucas  found 
23  cases,  18  of  which  followed  ophthalmia  neonatorum.  One  or  more 
joints  may  be  affected  after  any  of  the  diseases  mentioned.  The  chron- 
icity  of  the  disease  and  the  fact  that  it  occurs  in  the  course  of  one  of  the 
above-mentioned  diseases  serve  to  differentiate  it  from  rheumatism. 
In  gonorrhea  the  diplococcus  has  been  found  in  the  joint  by  aspiration. 
This  is  also  true  of  the  meningococcus  in  the  joint  troubles  of  meningitis. 


RHEUMATISM  579 

Septic  arthritis  is  really  a  form  of  the  above,  being  a  septic  infection 
of  the  joint.  In  many  cases  there  is  a  definite  source  of  infection,  an 
abscess,  or  something  of  the  kind.  In  some  cases  the  original  source 
of  infection  cannot  be  found  or  is  overlooked,  and  the  joint  is  the  first 
thing  noticed.  The  diagnosis  can  usually  be  made  from  the  fact  that 
the  temperature  is  liable  to  be  higher  and  both  local  and  constitutional 
disturbance  very  mucH  greater  than  found  in  rheumatism. 

Acute  osteomyelitis  is  also  important,  for  if  the  diagnosis  is  not  made 
and  the  bone  opened,  death  is  liable  to  result.  There  is  high  fever,  serious 
constitutional  disturbance,  and  the  swelling  is  above  rather  than  about 
the  joint.  Acute  arthritis  of  infants  is  usually  seen  in  rather  young 
infants.  There  is  a  rapid  effusion  into  the  joint,  which  either  starts  as 
a  purulent  effusion  or  rapidly  becomes  so.  The  knee  or  hip  is  usually 
the  joint  affected,  but  the  elbow  and  other  joints  may  be.  As  a  rule, 
but  one  joint  is  affected.  The  size  of  the  effusion,  the  high  fever,  marked 
local  and  constitutional  disturbance  make  the  diagnosis  possible.  When 
in  doubt  it  is  better  to  use  an  aspirating-needle  than  to  wait,  as  the  joint 
may  be  rapidly  destroyed  if  not  drained,  i^cute  articular  gout  is  not  seen 
under  seven  years  of  age.  The  presence  of  gouty  deposits  and  a  careful 
examination  of  the  vn-ine  and  marked  heredity  might  make  the  case  clear 
in  older  children.  Many  indefinite  s}Tiiptoms  not  unlike  rheumatism 
have  been  described  in  the  children  in  gouty  families.  The  effect  of 
diet  on  these  is  of  some  help  in  determining  their  nature.  Effusion  of 
blood  into  the  joints  sometimes  occurs  in  bleeders.  (See  article  on 
Hemophilia.)  The  fact  that  the  child  is  a  bleeder  and  the  nature  of  the 
effusion,  the  absence  of  fever  (not  always  absent,  however),  and  of 
other  symptoms  help  in  the  diagnosis. 

In  this  volume  some  of  the  diseases  liable  to  })e  mistaken  for  chronic 
rheumatism,  as  well  as  that  condition,  will  be  gone  over  with  the  differen- 
tial diagnosis  under  each.  It  should  be  remembered  that  rheumatism 
itself  rarely  leaves  any  permanent  joint  changes.  This  is  especially  true 
in  early  life.  ^Miere  there  are  chronic  joint  changes  with  grating, 
abnormal  deposits  and  the  like,  it  is  almost  certain  that  the  disease  is 
not  rheumatism.  The  importance  of  bearing  this  in  mind  is  to  avoid  in 
such  cases  the  constant  use  of  antirheumatic  remedies  which  do  not 
influence  the  other  diseases  and  which  in  themselves  may  be  prejudicial 
to  health  if  kept  up  for  any  length  of  time. 

Prognosis. — In  children  this  is  in  a  general  way  good.  Barring  com- 
plications the  child  is  certain  to  recover,  but  one  can  never  be  sure  that 
there  will  not  be  involvement  of  the  heart.  Each  attack  of  rheumatism 
predisposes  to  another  attack. 

Treatment. — The  treatment  of  acute  rheumatism  is  not  as  satisfactory 
as  it  might  be;  pain  can  usually  be  relieved  and  the  patient  rendered  com- 
fortable; just  how  much  the  disease  can  be  cut  short,  if  at  all,  is  a  ques- 
tion, and  we  have  no  way  of  preventing  the  heart  from  being  affected. 

The  child  should  be  put  to  bed  and  kept  there  until  all  traces  of  the 
disease  ha^-e  disappeared.  It  is  better  to  keep  the  patient  in  bed  a  few 
days  too  long  than  to  let  him  up  too  soon.     He  should  be  carefully 


580 


IXFECTIOUS  DISEASES 


tMiimled  against  chilling  anil  should  be  between  blankets  or  have  long 
fiannel  gowns.  When  he  gets  up  he  should  wear  flannel  underwear  and 
be  kei)t  out  of  the  damp,  cold,  and  draughts.  The  did  which  is  best 
suited  to  rheumatism  is  a  nuitter  of  some  difference  of  opinion.  Some 
authors  reconuueiid  farinaceous  foods,  and  others,  notably  Holt,  recom- 
mend the  use  of  nitrogenous  food  and  the  restriction  of  the  starches. 
While  the  child  has  fever  the  diet  should  be  largely  composed  of  milk. 
This  may  have  lime-water  or  Vichy  added  to  it,  or  barley  or  oatmeal 
gruel.  Broths,  custards,  juidvct,  and  gruels  may  be  used  to  vary  the 
diet.  If  the  urine  is  examined  daily  it  will  show  the  influence  of  diet. 
While  there  can  be  no  doubt  that  the  average  febrile  rheumatic  patient 
does  better  on  a  non-nitrogenous  than  on  a  nitrogenous  diet,  there  are 
pati(>nts  who  have  sul)acute  sym})toms  who  seem  to  require  meat  in  their 
dietary.  Urine  that  is  persistently  acid  may  be  caus(>(l  in  suc-h  cases  by 
an  intestinal  fermentation  and  the  use  of  too  large  a  quantity  of  farin- 
aceous food,  so  that  meat  simply  serves  to  lessen  the  hitestinal  indiges- 
tion without  apparently  increasing  the  nitrogenous  waste.  \Nhen  the 
fever  disap])ears  milk  should  still  be  used  as  much  a,s  possible,  but  the 
green  vegetal)les  may  be  added,  and  meats  and  eggs  may  be  given,  but 
they  should  not  be  allowed  with  acute  symptoms  or  where  there  is  any 
question  of  nitrogenous  excess.  The  food  should  then  be  easy  of 
digestion  and  of  good  quality. 

Therapeutics. — I/)cally  I  have  used  Fuller's  lotion  as  recommended 
by  Osier.  This  consists  of  carbonate  of  soda,  24  gm.  (G  dr.);  lau- 
danum, 30  c.c.  (1  oz.);  glycerin,  60  c.c.  (2  oz.);  and  water,  270  c.c. 
9  oz.).  It  should  be  applied  hot  on  flannel  cloths.  Chloroform  liniment 
may  also  be  used.  If  the  joint  Is  very  painful,  it  should  be  fixed  by 
wra])ping  it  in  a  generous  roll  of  cotton  and  bandaging  to  a  well-padded 
splint.  In  older  children  the  joint  may  be  "fired"  by  using  a  Paquelin 
cautery,  which  should  be  heated  to  a  dull  red  and  passed  to  and  fro 
rather  rapidly,  just  close  enough  to  the  skin  to  cause  a  glossy  redness 
to  ap])(nir.  Great  care  should  be  taken  not  to  produce  any  definite  burns. 
With  a  little  pi'actice  this  is  easily  done  and  affords  great  relief. 

Internally  salicylic  compounds  may  be  used  or  alkalies.  Of  the 
former  there  are  a  number  to  choose  from.  Salicin  is  one  of  the  best  for 
children.  It  is  usually  better  borne  than  the  others  and  is  not  so  depress- 
ing. It  may  be  given  in  doses  of  about  0.06  gm.  (1  grain)  for  each 
year  of  the  child's  age,  and  this  amount  should  be  repeated  every  hour 
or  every  two  hours  until  the  pain  is  relieved.  After  that  it  may  be  given 
every  three  or  four  hours  and  later  on  the  dose  reduced  in  size. 

Salicin  is  inodorous,  but  very  bitter,  with  the  peculiar  flavor  of  the 
bark.  In  older  children  it  may  be  given  in  capsules.  It  is  not  well  to 
make  the  capsules  larger  than  0.26  gm.  (4  gr.)  each.  If  the  child 
cannot  swallow  a  capsule  it  may  be  given  in  some  flavored  syrup.  Salicin 
is  soluble  in  about  30  parts  of  water. 

9;— Salicini 1.55  gm.       (gr.  xxiv). 

Syrupi  aurantii 90.00  c.c        (Siij). 

Sig.— A  teaspoonful  every  two  hours.    From  one  to  two  years  of  age, 


RHEUMATISM  5gX 

Salicylic  acid  is  almost  insoluble  in  water,  is  tasteless,  but  leaves  a 
sense  of  bitterness  and  astringency  in  the  mouth.  It  is  quite  efficacious 
in  stopping  pain,  but  it  may  be  very  depressing.  The  pulse  rate  may 
be  greatly  decreased  by  its  use.  The  dose  is  about  0.03  gm.  {h  gr.)  for 
each  year  of  the  child's  age.  It  may  be  given  in  tablets  or  capsules.  The 
follov/ing  has  been  advised  as  a  pleasant  way  of  giving  it  in  solution: 

Jfc—Acidi  salicylic! 4.0  gm.  (5j). 

OL  amygdal.  express! 20.0  e.c.  (5v). 

Pulv.  acaciffi 10.0  gm.  (Siiss). 

Syr.  amygdalae 24.0  e.c.  (5vj). 

Aq.  aurantii  florum         .        •        .        .        .        .     q,  s.  ad  90.0  e.c.  (Siij). 
Sig. — A  leaspoonful  every  two  or  three  hours. 

The  salicylate  of  soda  is  quite  soluble  (in  1.5  parts  of  water),  but  may 
be  rather  nauseating.  To  young  infants  it  is  best  given  in  plain  aqueous 
solution  or  with  a  flavored  water,  as  peppermint-  or  cinnamon-water. 
For  older  children  it  may  be  put  up  with  syrup  of  orange,  syrup  of  rasp- 
berry, or  aromatic  elixir. 

Oil  of  wintergreen,  consisting  almost  entirely  of  methyl  salicylate, 
may  be  given  in  place  of  any  of  the  above.  It  may  be  administered  in 
simple  syrup. 

Aspirin  may  be  given  in  place  of  the  above.  The  dose  is  the  same  as 
salicylate  of  soda.    It  is  soluble  in  about  100  parts  of  water. 

The  salicyl  derivatives  should  not  be  discontinued  as  soon  as  the  pain 
stops,  but  kept  up  in  smaller  doses  for  several  days  or  a  week,  or  longer 
if  necessary.  If  they  are  stopped  too  soon  pain  and  other  rheumatic 
symptoms  may  return.  It  is  well  to  give  these  patients  treatment 
for  one  or  two  weeks  at  a  time  for  a  period  covering  a  number  of 
months. 

The  salicyl  derivatives  may  only  act  as  irritants  to  the  stomach  in 
some  cases,  and  where  this  happens  they  must  be  abandoned  and  alkalies 
given  instead.  It  is  well  to  use  Vichy  water  in  all  cases.  In  addition  to 
this  bicarbonate  of  soda  or  the  acetate  or  citrate  of  potassium  may  be 
given.  The  latter  is  conveniently  given  with  syrup  of  lemon  and  water. 
Sufficient  should  be  given  to  render  the  urine  alkaline,  and  then  the  dose 
reduced  so  that  the  urine  is  kept  slightly  alkaline.  From  0.06  to  0,3  gm. 
(1  to  5  gr.)  of  any  of  the  above  at  a  dose  may  be  used,  or  more  if  neces- 
sary. ^Vhen  salicyl  derivatives  can  be  given  the  pain  can  generally  be 
controlled,  but  when  they  are  not  well  borne,  opium,  in  the  form  of 
Dover's  power,  or  morphine  in  small  doses  may  be  given  to  control  it. 

The  after-treatment  of  rheumatism  is  very  important.  Iron  for  the 
anemia  and  small  doses  of  quinine  or  strychnine  are  very  useful  in  burld- 
ing  up  the  little  patients.  Cod-liver  oil  is  of  great  service.  Such 
children  require  a  large  amount  of  fatty  food.  An  out-of-door  life  in 
a  dry  climate  benefits  many  patients. 

Chronic  Fibrous  Rheumatism. — This  is  a  rare  disease  in  children. 
It  has  been  described  by  Jaccoud  and  others.  The  lesion  consists  of  a 
thickening  of  the  tissues  about  the  joint  and  of  the  joint  capsule  itself. 
It  may  develop  after  several  attacks  of  acute  rheumatism,  and  is  said 
sometimes  to  come  on  insidiously  without  any  very  acute  symptoms 


582  iXFECTiors  diseases 

ever  being  noticed.  Several  joints  arc,  as  a  rule,  affected.  TIhmv  may 
be  endocarditis  or  ])cricanlitis,  and  rheumatic  nodules  Inivc  been  noted 
in  some  cases. 

Diagnosis. — This  is  made  on  the  repeated  attacks  of  rhenmatism,  the 
heart,  or  other  lesions,  and  the  nodules  when  present. 

Prognosis. — Prot^nosis  as  regards  life  is  good,  but  as  regards  cure  is 
bad,  as  the  joints  are  apt  to  remain  uninfluenced  by  treatment. 

Treatment. — Jaccoud  claims  to  have  gotten  good  results  from  the  use 
of  the  salicyl  derivatives.  They  are  not  adapted  for  continuous  use, 
however.  Iodide  of  potassium  may  be  tried,  and  guaiacum  has  been 
recommended.  If  there  is  pain  the  administration  of  methyl  salicylate 
O.bS  c.c.  (3  ^,)  with  colchicin,  0.0002")  gnLf^io"  gr.),  given  in  a  globule 
several  times  a  day,  may  be  used,  l^ocal  treatment  is  probably  more 
effective  in  giving  relief.  "  Firing"  with  the  Paquelin  cautery,  as  men- 
tioned on  p.  580,  or  any  mild  form  of  counterirritation,  may  he  used. 
Between  the  attacks  of  pain,  massage  and  passive  movements  do  much 
to"  prevent  ankylosis  and  stiffness  of  the  joint.  The  use  of  hot  air  at  high 
temperatures  may  be  tried.  If  possible  the  patient  should  spend  the 
winter  or  damp  months  in  a  dry,  equable  climate.  Visits  to  hot  springs 
sometimes  give  relief,  (lood  food,  tonic  treatment,  and  a  (juiet  out-of- 
door  life  are  the  best  things  when  the  patient's  means  allow  them. 


ARTHRITIS  DEFORMANS. 

Arthritis  Deformans,  or,  as  it  is  called  by  some  authorities,  Rheuma- 
toid Arthritis,  is  not  very  common  in  childhood,  but  it  is  sometimes  met 
with.  Many  eases  are  mistakenly  called  rheunuitism.  In  11  out  of  92 
eases  reported  by  McCrae,  the  disease  began  before  ten  years  of  age. 
The  etiology  is  obscure.  In  some  there  is  a  distinct  family  history  of 
joint  troul)les. 

Pathology. — -This  is  not  fully  understood,  "^rhere  seem  to  be  two 
classes  of  cases.  In  one  there  is  an  hypertro[)hy  of  the  bone  with  the 
formation  of  exostoses  and  considerable  new  bony  tissue,  the  joints 
looking  as  if  liquid  bone  had  been  poured  on  them  and  allowed  to  harden. 
In  the  second  class  there  is  an  atrophy  of  the  bones  and  of  the  tissues 
about  the  joints.  In  both  there  is  likely  to  be  marked  deformity.  Later 
in  either  case  there  may  be  thinning  of  the  cartilages  and  degenerative 
changes  in  the  joint,  leading  to  more  or  less  complete  ankylosis.  In  the 
first  class  of  eases  there  may  he  immobility  due  to  the  al)normal  de])osits 
of  bone  "soldering,"  as  it  were,  the  bones  together. 

Symptomatology. — Clinically,  the  cases  may  be  grouped  roughly  under 
two  heads:  First,  those  where  there  are  acute  attacks  of  arthritis  with 
remissions,  during  which  the  joint  is  apparently  normal,  each  attack 
leaving  the  joint  more  disabled,  however,  until  fiiuilly  it  may  be  almost 
or  entirely  useless.  Sec-ondly,  those  where  there  is  a  gradual  onset  with 
progressive  joint  changes.  There  is  sooner  or  later  atrophy  of  the 
muscles  and  deformity. 


RHEUMATISM  533 

In  the  acute  attacks  there  is  swelHng  of  the  joint  with  some  pain  and 
tenderness,  httle  or  no  temperature,  and  a  rapid  pulse  rate. 

In  all  cases  there  is  usually  involvement  of  the  lymph  nodes.  The 
spleen  was  enlarged  in  only  4  of  30  cases  studied  by  McCrae  (including 
aduhs  and  children).  In  the  acute  form  in  children  known  as  Still's 
disease  the  spleen  is  enlarged.  Xodules  similar  to  the  rheumatic  ones  or 
identical  with  them  are  found  in  some  cases. 

Diagnosis. — This  can  be  made  if  one  bears  in  mind  the  features  of  the 
disease.  From  acute  articular  rheumatism  the  attacks  differ  in  the  fol- 
lowing points:  There  is  much  swelling  with  comparatively  little  pain 
and  tenderness;  the  swelling  and  swptoms  do  not  disappear  rapidly  as 
in  rheumatism;  there  is  little  or  no  tendency  to  move  from  joint  to  joint; 
there  is  an  absence  of  other  rheumatic  sjTiiptoms;  there  is  little  or  no 
temperature,  but,  as  McCrae  has  pointed  out,  a  high  pulse  rate.  Later 
on  or  after  several  attacks,  there  is  deformity  of  the  joint ;  atrophy  of  the 
muscles  and  sometimes  increased  reflexes.  The  heart  is  not  involved, 
as  a  rule. 

Prognosis. — Prognosis,  as  far  as  complete  recovery  is  concerned,  is 
bad.  The  general  health  is  apt  to  be  poor  on  account  of  the  patient 
being  more  or  less  crippled. 

Treatment. — Treatment  of  the  acute  attacks  consists  in  rest  in  bed, 
flannel  clothing,  regulation  of  diet,  as  much  as  in  the  acute  attack  of 
rheumatism,  and  attention  to  the  bowels  and  general  condition.  "Firing" 
the  joint,  baking  with  hot  air,  or  other  mild  counterirritation  may  be 
tried  for  the  pain.  If  the  pain  is  very  severe,  antipyrin  or  phenacetin, 
combined  with  small  doses  of  codein,  gives  relief.  Koplik  states  that 
iodide  of  potassium  is  the  only  drug  which  relieves  the  pain.  Luff^ 
regards  guaiacol  carbonate  as  a  valuable  adjunct  to  the  iodide.  For 
gradual  forms  and  between  the  attacks,  a  good,  nutritious  diet,  with 
plenty  of  milk,  eggs,  and  meat;  out-of-door  life,  massage,  and  a'-rays 
are  recommended.  In  both  classes  of  cases  patient  supervision  is 
essential.  Massage  and  x-rays  without  oversight  and  direction  will 
not  do  any  good,  while  with  intelligent  direction  they  may  bring  about 
great  improvement. 

Spondylitis  Deformans. — This  is  sometimes  seen  in  children.  Usually 
not  under  thirteen  years,  however,  although  it  has  been  noted  earlier. 
It  is  a  form  of  osteoarthritis  affecting  the  spinal  column,  hips,  and 
shoulders.  It  leads  to  gradual  stiffening  of  the  back  and  the  affected 
joints.  Pressure  on  the  nerves  may  give  rise  to  pain  and  atrophy  of  the 
muscles.  It  is  likely  to  be  mistaken  for  Pott's  disease  or  for  rheumatism. 
Tuberculin  is  useful  in  excluding  tuberculosis.  The  cases  seen  early  and 
immobilized  in  plaster  casts  may  be  arrested,  otherwise  the  disease  goes 
on  to  produce  absolute  immobility  of  thespine  and  of  the  proximal  joints. 
(See  Ruhrah,  American  Journal  of  Medical  Sciences,  November,  1903.) 

Treatment.  What  has  been  said  of  the  treatment  of  arthritis  defor- 
mans applies  equally  well  to  this  form  of  that  disease, 

1  Clinical  Journal,  October  7  and  14,1903. 


584  INFECTIOUS  DISEASES 

Still's  Chronic  Joint  Disease.— This  is  a  curious  form  of  arthritis 
(U'fonnans  pecuHar  to  childiiood,  consisting  of  chronic  progressive 
euhirgcment  of  the  joints,  associated  with  enlargement  of  the  lymph 
nodes  and  of  the  spleen.  Garrod  believes  it  to  be  entirely  distinct  from 
the  recognized  arthritis  deformans.  It  usually  comes  on  before  the 
second  tlentition,  and  it  is  more  frequent  in  girls  than  in  boys.  The 
onset  is  generally  insidious,  but  nuiy  be  acute.  No  heart  changes  are 
recorded.  Lufi"'  gives  four  important  points  in  its  tliagnosis  from 
arthritis  deformans:  (1)  enlargement  of  the  lymph  nodes;  (2)  enlarge- 
ment of  the  s])Ieen;  (.3)  the  peculiar  apj)carance  and  doughy  feel  of  the 
joints  without  grating  or  bony  outgrowths,  and  (4)  the  involvement  of 
the  knees  or  wrists  with  the  fingers  secondarily  affected.  Treatment  is 
limited  to  diet  and  hygiene. 

Symptomatology. — 'J'he  enlarged  joints  both  feel  and  look  as  if  there 
was  a  thickening  of  the  tissues  about  the  joint  rather  than  of  the  bones 
themselves,  and  is  smooth  and  fusiform,  without  any  bony  irregularities 
of  the  rheumatoid  arthritis  of  adults.  There  is  no  grating,  although 
there  may  be  creaking.  There  is  neither  redness  nor  tenderness,  except 
in  acute  cases,  but  there  may  be  pain  on  motion.  There  is  practically 
alwavs  limitation  of  movement,  chiefly  of  extension.  The  child  may  be 
com})letely  bedridden  on  account  of  this.  The  joints  enlarged  are 
usually  the  knees,  wrists,  cervical  spine,  and  subsequently  the  ankles, 
elbows,  and  fingers. 

The  lymph  nodes  are  hard,  but  there  is  neither  tenderness  nor  any 
tendency  to  l)rcak  down. 

l^he  spleen  is  somewhat  enlarged  in  most  cases;  generally  it  reaches 
one  or  two  finger  breadths  below'  the  edge  of  the  ribs.  Both  spleen  and 
Ivmph  nodes  get  larger  as  the  joints  become  worse.  If  the  disease  begins 
before  the  second  dentition  there  is  usually  some  arrest  of  the  physical 
development  of  the  child.     The  mentality  is  not  affected. 

Prognosis. — Prognosis  as  far  as  life  is  concerned  is  good;  the  cases  that 
have  died  are  from  some  complicating  disease.  The  outlook  as  regards 
the  disease  itself  is  bad.  The  cases,  as  a  rule,  have  a  tendency  to  get 
worse  instead  of  better. 

Treatment. — Treatment  is  the  same  as  for  other  ciironic  joint  affections 
along  general  lines.    There  is  no  specific  treatment  known  as  yet. 

1  Clinical  Journal,  October  7  and  14, 1905. 


SECTION   VII. 
DISEASES  OF  THE  RESPIRATORY  TRACT. 

By  CLIVE  riviere,  M.D.,  M.R.C.P.,  London,  M.R.C.S.,  England. 


CHAPTEK   XXIII. 

DISEASES  OF  THE  NOSE— NASOPHARYNX— LARYNX. 
ACUTE  NASAL  CATARRH. 

This  complaint,  the  familiar  "cold  in  the  head,"  is  even  more  readily 
induced  in  children  than  in  those  of  more  advanced  years. 

Etiology. — Nasal  catarrh  occurs  as  a  symptom  of  many  of  the  exanthe- 
mata; when  primary,  it  is  almost  certainly  of  bacterial  origin,  and  it  is 
more  than  probable  tliat  many  varieties  of  organism  are  capable  of  caus- 
ing it.  The  nasal  mucous  membrane  must  possess  a  remarkable  power 
of  dealing  with  the  numerous  bacteria  which  are  constantly  entering 
with  the  air  stream,  since  the  nasal  cavities  in  health,  when  once  the 
external  orifice  is  passed,  are  practically  sterile.  When  nasal  catarrh  is 
present,  on  the  other  hand,  cultures  from  the  mucous  surface  show  a 
large  gro\\i;h  of  colonies,  consisting,  as  a  rule,  of  one  organism  in  abun- 
dance, probably  the  causative  agent  in  that  particular  case,  and  a  few 
colonies  of  other  varieties  besides.  Acute  nasal  catarrh  is  "caught" 
in  two  separate  ways :  First,  it  may  be  set  up  by  a  lowering  of  natural 
resistance  through  exposure  to  cold  or  damp,  by  violent  purgation  in 
enteritis,  etc.,  the  organism  being  already  present;  or,  secondly,  it  may 
be  handed  on  by  personal  contact,  so  that  it  becomes  a  "household 
cold."  In  this  case  the  organism  probably  acquires  an  enhanced 
virulence,  and  individual  immunity  is  readily  overcome. 

Symptomatology. — "  Colds"  vary  somewhat  in  the  prominence  of  their 
symptoms.  When  severe  the  sufferer  may  experience  some  chilliness, 
with  headache  and  malaise  at  the  onset.  The  nasal  mucous  membrane 
is  at  first  turgid  and  dry,  but  soon  a  watery  secretion  appears,  and  the 
swelling  increases,  so  that  nasal  respiration  becomes  difficult  or  even 
impossible.  This  obstruction  is  most  marked  in  the  recumbent  posture, 
causing  much  discomfort  at  night,  while  in  infants  attacks  of  suffocation 
may  result  and  breast  feeding  be  greatly  interfered  with.     After  a  time 

(  585) 


580  DISh'ASKS  OF   THE  RESPIUATORY    TRACT 

tlu-  watery  secretion  increases  and  at  the  end  of  a  day  or  two  becomes 
consideral)le  in  (plant ity,  the  swi  Uin<f  of  the  nnicons  nu'nil)rane  at  the 
same  time  lessenin*;',  so  that  nose  hreathin*;  becomes  easier.  The  dis- 
charge is  thicker  and  less  in  (juantity  as  time  goes  on,  passing  throngh 
the  stages  of  sernm,  seromncns,  mucopus,  and  finally  drying  up  alto- 
(^ether  after  a  period  varying  from  one  to  two  weeks.  The  child  is  lan- 
guid during  the  attack  and  unfit  for  any  exertion,  but  brightens  up 
somewhat  after  the  first  two  or  three  days  are  past.  In  most  cases  the 
catarrh  is  preceded  by  some  amount  of  pharyngitis;  occasionally  it  starts 
in  the  nasopharynx,  especially  when  adenoids  are  present,  and  spreads 
thence  to  both  nose  and  pharynx.  In  either  case  there  is  a  great  ten- 
dency for  the  j)rocess  to  pass  downward  to  the  lower  respiratory  passages, 
and  this  constitutes  the  chief  danger  of  nasal  catarrh  in  childhood. 

Treatment. — Recurring  "colds"  in  children  must  not  be  treated  lightly; 
thev  may  lead  to  bronchitis  and  bronchopneumonia.  A  cause  must  be 
carefully  sought  in  ill-ventilated  or  overheated  nurseries,  in  digestive 
disorders,  in  injudicious  exposure  during  bathiiig,  or  in  c<;ld  extremi- 
ties from  insufficient  covering,  and  the  cause  removed  before  local  and 
general  treatment  will  prove  of  service. 

At  the  onset  of  catarrh  a  hot  bath  may  be  given  with  a  hot  lemon  drink 
containing  some  such  diaphoretic  as  spirits  of  nitrous  ether,  O.nO  c.c. 
(rr[x)  for  a  child  of  one  year,  or  acetate  of  ammonia,  0.125  c.c.  (itlxx)  of 
the  li(juor,  and  the  child  put  to  bed,  or,  at  any  rate,  confined  to  one  room. 
If  the  pharynx  is  congested  it  maybe  sprayed  three  or  four  times  daily 
with  an  antiseptic  solution,  such  as  izal*  (l  to  1  per  cent,  sol.)  or  listerine 
(1  in  S),  or  an  older  child  may  use  a  weak  solution  as  a  gargle.  In 
infants  a  few  drops  of  a  1 :  1000  solution  of  adrenalin  chloride  or  a  solution 
of  cocaine  (2  per  cent,  in  water  or  1  per  cent,  in  liquid  paraffin  or  albo- 
lene)  may  be  instilled  into  the  nostrils  immediately  before  suckling  to 
clear  the  nose  by  constringing  the  swollen  membrane.  After  the  "dry" 
stage  of  the  cold  is  passed,  quinine  should  be  given  in  tonic  doses  of 
from  O.OGo  to  0.13  gm.  (1  to  2  gr.),  and  if  this  causes  headache,  and 
more  especially  if  the  throat  continues  sore,  salicylate  of  soda  may  be 
given  at  the  same  time,  0.2  to  0.3  gm.  (3  to  5  gr.)  for  every  grain  of 
f|uinine  prescril)ed. 

These  drugs  are  best  given  in  separate  mixtures,  as  they  are  not 
readily  combined.  Quinine  may  sometimes  be  given  at  the  onset  with 
advantage,  and  has  some  reputation  as  a  means  of  cutting  short  the 
attack.  The  association  of  the  acute  form  of  nasal  catarrh  with  gastric 
and  intestinal  disturbances  must  be  remembered.  Soda  in  th.e  form  of 
the  bicarbonate  is  often  of  value  in  this  class  of  cases  and  a  laxative  is 
helj)ful.  The  child  should  be  kept  indoors  for  the  first  few  days,  espe- 
cially if  there  is  any  liability  to  bronchitis,  but  when  the  secretion  becomes 
mucoj)urulent  lie  may  generally  begin  to  go  about  if  the  weather  is  fine 
and  gradually  resume  his  ordinary  methods  of  life. 

'  Izal  is  a  by-product  in  coke  making.    It  is  insoluble  in  water,  but  forms  with  it  a  fine  emulsion. 
It  possesses  powerful  germicidal  action. 


DISEASES  OF   THE  NOSE  537 


CHRONIC  NASAL  CATARRH. 

Etiology. — In  infants  this  is  commonly  due  to  congenital  syijhilis,  but 
may  be  caused  by  congenital  adenoid  g^o\^1:hs.  In  older  children  it  is 
generally  associated  with  the  presence  of  adenoids  in  the  nasopharynx; 
more  rarely  polypi,  whether  mucous  or  fibrous,  may  be  the  cause,  or  the 
later  syphilitic  lesions  with  gummata  and  ulceration  may  be  present. 
A  foreign  body,  as  a  button,  is  sometimes  responsible  for  a  unilateral 
discharge  in  young  children.  An  acute  nasal  catarrh  may  be  followed 
by  a  period  of  discharge  that  may  simulate  the  chronic  form  due  to 
other  causes. 

Symptomatology. — The  symptoms  consist  of  nasal  discharge  with  the 
resulting  snuffling  and  sniffing,  and  more  or  less  obstruction  to  nasal 
respiration.  This  last  may  be  due  to  the  adenoid  growths  so  often 
underlying  the  condition  rather  than  to  the  condition  itself.  The  dis- 
charge is  generally  mucopurulent,  or  even  purulent,  and  readily  causes 
excoriation  of  the  upper  lip;  if  due  to  a  foreign  body  it  is  unilateral,  and 
often  blood-stained.  In  cases  of  late  syphilitic  ulcei-ation,  or  in  rare 
cases  of  atrophic  rhinitis,  it  may  be  of  very  offensive  odor.  The  condi- 
tion of  the  mucous  membrane  varies  greatly  in  different  cases;  it  com- 
monly appears  red  and  sticky,  and  may  be  hypertrophied,  so  that  the 
passage  is  occluded,  or  in  rare  cases  atrophied  and  coated  with  crusts. 
In  late  syphilitic  cases  the  nasal  bones  often  fall  in,  giving  the  familiar 
saddle-back  deformity,  or  perforation  of  the  hard  palate  may  occur. 

Treatment. — The  cause  must  be  removed,  whether  this  be  adenoid 
growths,  polypi,  or  a  foreign  body.  The  two  latter  are  reached  from  the 
anterior  nares,  the  mucous  membranes  being  first  sprayed  or  painted 
with  a  2  to  5  per  cent,  solution  of  cocaine, which  acts  both  as  a  constringent 
and  as  a  local  anesthetic.  Pol}^i  are  removed  with  the  snare,  or  a  for- 
eign body  coaxed  out  with  a  hairpin,  or  grasped  with  a  fine  forceps.  In 
cases  of  hypertrophic  rhinitis  the  swollen  mucous  membrane  must  be 
cauterized,  an  alkaline  or  mild  astringent  douche  (^  per  cent,  solution 
of  alum)  being  used  in  the  intervals.  For  atrophic  rhinitis  an  alkaline, 
antiseptic  spray  is  necessary  to  loosen  the  crusts,  such  as  borax  and 
sodium  bicarbonate,  0.3  gm.  (5  gr.)  of  each  to  30  c.c.  (1  oz.),  the  cavi- 
ties being  afterward  lubricated  and  made  clean  by  a  spray  of  from  2  to 
10  per  cent,  menthol  in  liquid  paraffin  or  alboline. 


DISEASES  OF  THE  NASOPHARYNX. 

ADENOID  GROWTHS. 

Etiology. — The  pharyngeal  tonsil  lies  in  the  roof  of  the  pharynx, 
extending  somewhat  on  to  its  posterior  wall.  It  consists  of  a  mass  of 
lymphoid  tissue,  as  does  the  faucial  tonsil,  and  is,  in  truth,  but  a  lym- 
phatic gland  of  peculiar  relationship.     Its  overgrowth  constitutes  the 


588 


DISEASES  OF   THE   RESPIRATORY   TRACT 


disease  known  as  "  adenoids, "  tlie  main  sy]nj)tonis  of  wliicli  are  dne  to 
ohstrnction  of  the  posterior  nares.  In  a  certain  j)ro|)ortion  of  eases,  30 
per  eent.  aeeordinijj  to  some  writers,  this  ()ver<j;r()wth  is  associated  with 
a  similar  condition  of  the  faueial  tonsils.  When,  on  the  other  hand, 
enlargement  of  the  tonsils  is  found  in  children  adenoid  growths  are 
present  in  addition  in  *)U  per  eent.  of  the  cases.  The  growths  generally 
have  a  wide  attachment,  and  project  as  vegetations  corresponding  to 
the  divisions  of  the  gland.  They  are  either  soft,  when  they  bleed  very 
readily,  or  firm  from  fibrous  overgrowth.  This  difference  bears  no 
relation  to  age,  firm  adenoids  being  often  found  in  the  youngest  sub- 
jects. 

Adenoids  are  found  at  all  ages,  and  are  not  infre(|uently  congenital,  a 
fact  which  is  too  commonly  overlooked.  An  hereditary  tendency  appears 
to  be  present  in  some  cases. 

Symptomatology.  In  Infants. — The  sym})toms  may  appear  at  birth 
or  be  noticed  soon  after.    The  infant  snuffles  loudly,  and  often  there  is 

considerable  nasal  discharge ;  the 
^"^-  ^29  nasal   obstruction  may  interfere 

with  suckling,  and  the  children 
are  liable  to  attacks  of  suffoca- 
tion during  sleep.  Occasionally 
they  are  brought  to  the  physician 
for  the  treatment  of  reflex  ner- 
vous phenomena,  such  as  con- 
vulsions, laryngismus,  or  vomit- 
ing. These  may  be  associated 
with  growths  too  small  to  cause 
obstruction,  or  may  occur  in  cases 
j)resenting  the  gross  symptoms 
described  above.  The  typical 
adenoid  facies  is  not  seen  in 
young  infants,  but  the  signs  are 
usually  sufficiently  definite  to 
form  the  basis  for  a  diagnosis. 
Snuffling  is  very  noticea!)le  and  is 
due  to  the  presence  of  abundant 
secretion;  the  nostrils  are  round 
and  dilated,  not  flattened  laterally,  as  generally  occurs  in  older  children. 
On  examining  the  throat  the  tonsils  may  be  somewhat  enlarged,  but  in 
infancy  the  adenoids  camiot  always  be  reached  by  the  finger,  owing  to 
the  smallness  of  the  nasopharynx.  In  cases  wjiere  the  gro\\1:hs  are 
small  the  symptoms  only  appear  at  such  times  as  the  obstruction  is 
increased  by  acute  catarrh. 

In  Older  (liildrcn.—Thv  symptoms  often  first  appear  after  some  illness 
associated  with  catarrh,  such  as  scarlet  fever,  measles,  or  whooping- 
cough,  'rhe  attention  may  be  drawn  to  the  condition  either  by  certain 
ear  complications  or  by  the  nasal  obstruction  itself,  and  many  cases  are 
first  seen  on  account  of  recurrent  attacks  of  bronchitis  and  nasal  catarrh. 


Usual  expression  of  a  boy  with  adenoids. 


DISEASES  OF   THE  NASOPHARYNX  589 

In  a  marked  case  the  appearance  of  the  child  is  very  typical;  the 
mouth  is  open  and  the  jaw  dropped,  giving  a  vacant  expression  to  the 
face  (Fig.  129);  the  lips  and  tongue  are  dry,  the  eye  is  watery  and 
injected,  and  the  nostrils  may  be  mere  slits,  the  alaj  being  flat  and  expres- 
sionless. Nasal  discharge  is  generally  obvious  and  may  cause  excoriation 
of  the  upper  lip. 

The  child  snores  at  night  and  may  wake  half-suffocated  at  intervals, 
often  with  night-terrors,  the  voice  is  nasal  and  toneless,  headache  is 
common  and  mental  processes  dulled,  taste  and  smell  are  deficient,  and 
in  some  cases  the  child  has  difficulty  in  swallowing  and,  when  young, 
regurgitates  his  food.     Incontinence  of  urine  is  sometimes  present. 

Ear  complications  are  common  and  some  deafness  the  rule.  A  naso- 
pharyngeal catarrh  is  constantly  present,  and  attacks  of  pharyngitis, 
laryngitis,  and  bronchitis  frequently  arise,  but  apart  from  these  a  bark- 
ing cough  may  be  present  as  a  reflex  phenomenon.  Habit  spasm  is 
observed  in  some  cases. 

Deformities  appear  in  connection  with  the  condition;  in  the  face 
growth  is  hindered,  leading  to  the  narrow  jaw  with  crowded  teeth  and 
the  high -arched  palate.  In  the  chest  alteration  of  shape  may  arise; 
pigeon-breast  with  a  deep  Harrison's  sulcus  occurs  in  some  cases,  but 
the  most  typical  deformity  is  the  formation  of  a  hollow  at  the  lower  end 
of  the  sternum;  this  may  be  observed  in  process  of  formation,  the 
parts  being  sucked  in  with  each  inspiration. 

Diagnosis. — This  can  usually  be  made  from  the  appearance  of  the 
patient,  and,  on  inspecting  the  pharynx,  relaxation  of  the  soft  palate, 
lymphoid  masses  on  the  pharyngeal  wall,  and  often  enlargement  of  the 
tonsils  will  be  noticed.  Having  decided  that  some  nasal  obstruction  is 
present  it  is  better  to  defer  examination  of  the  nasopharynx,  especially 
in  a  young  child,  until  an  anesthetic  has  been  given  and  the  patient  pre- 
pared for  operation;  the  child  is  thus  spared  the  distress  which  a 
digital  examination  without  an  anesthetic  occasions.  Other  conditions 
which  may  simulate  the  obstruction  of  adenoids  are:  1.  Bony  obstruction 
due  to  insufficient  size  of  the  posterior  nares,  a  low  pharyngeal  vault, 
prominence  of  the  crest  of  the  vomer,  or  a  forward  projection  of  the 
vertebral  column.  These  are  liable  to  occur  in  ill-nourished  and  rickety 
children.  2,  Thickening  of  soft  parts  throughout  the  nose  and  over  the 
internal  pterygoid  plate  and  tuberosity  of  the  palate.  3.  New-growths 
other  than  adenoids.    4.  Retropharyngeal  abscess. 

In  young  children  snuffling  is  generally  the  most  noticeable  symptom 
and  suggests  the  presence  of  congenital  syphilis.  The  absence  of  a 
syphilitic  family  history,  of  specific  eruption,  and  of  the  anemia  with 
yellow  skin  commonly  found  in  this  disease  will  generally  serve  to  dis- 
tinguish them..  The  dilated  nostril,  so  often  seen  with  adenoids  in  infancy, 
may  be  of  assistance. 

Treatment. — When  the  condition  is  found  in  early  infancy  surgical 
measures  may  be  delayed  if  the  symptoms  of  obstruction  are  lessened 
by  other  treatment,  and  the  coincident  catarrh  is  not  severe.  Opera- 
tion in  early  infancy  is  difficult,  and  too  much  must  not  be  prom- 


51K)  DISEASES  OF   THE   liESl'lUATOliV    TRACT 

iscd  as  it  is  likely  to  he  ineomplete.  The  catarrh  which  inereases  the 
ohstriietion  can  often  he  kept  in  aheyanee  hy  instiiliiiiij  a  few  drops  of  a 
1  per  cent,  solution  of  resorcin  into  the  nostrils  four  or  five  times  daily, 
and  for  the  nervous  phenomena  sedatives  may  be  tried.  Every  plan  for 
huildiufT  up  and  streui^hening  the  mucous  memhrane  should  he  used. 
()j)cration  is,  however,  sometimes  performed  with  good  results  as  early 
as  the  third  or  fourth  mouth. 

In  older  children  it  is  well  to  wait  until  any  acute  contlition,  such  a,s 
bronchitis,  is  past  before  an  operation  is  undertaken,  but  treatment  must 
not  he  needlessly  postponed,  owin<;  to  the  deleterious  efi'ect  of  the  ade- 
noids on  the  general  health,  the  danger  of  ear  com})licatious,  and  the 
liability  to  diphtheria  and  scarlet  fever  which  the  condition  of  the  naso- 
pharynx entails.  The  patient  is  prepared  for  the  administration  of  an 
anesthetic,  chloroform  being  that  most  commonly  chosen  in  England  and 
ether  in  America.  When  the  child  is  "under"  the  anesthetic,  the  head 
is  hung  over  the  end  of  the  operating-table  and  the  adenoids  palpated. 
Enlarged  tonsils,  if  present,  are  removed  with  the  guillotine.  Ade- 
noids are  most  readily  removed  with  a  (Jrottstein  curette.  The  sharp 
ring  is  passed  behind  the  soft  palate,  and,  with  a  downward  movement 
of  the  handle,  the  adenoids  are  cut  from  before  backward,  often  coming 
out  as  a  single  mass,  'i'he  parts  are  palpated  with  the  left  forefinger, 
and  the  cutting  process  repeated  till  the  space  is  clear.  Forceps  are  pre- 
ferred by  some  operators,  in  which  case  care  shoidd  be  taken  to  avoid 
injury  of  the  entrance  to  the  Eustachian  tubes  or  the  nasal  septum. 
Hemorrhage  is  smart,  hut  rpiickly  ceases.  Douching  or  otlier  after- 
treatment  is  best  avoided,  and  blowing  the  nose  should  be  prohibited 
for  a  day  or  two.  Occasional  troubles  arising  as  the  result  of  operation 
are  stiff  neck,  otitis  media,  and  infection  w^ith  scarlet  fever  or  diphtheria. 
A  white  slough  on  the  stump  of  the  tonsil,  often  present  after  the  opera- 
tion, must  not  be  mistaken  for  the  membrane  formed  by  the  latter 
disease. 

After  the  adenoids  have  been  removed  education  in  nasal  breathing 
is  required,  or  a  child  may  remain  a  mouth-breather  from  mere  habit. 


ACUTE  PHARYNGITIS. 

The  two  conditions,  Acute  and  Chronic  Pharyngitis,  which  have  been 
described  (p.  102),  ar(>  briefly  mentioned  here  l)ecause  of  their  associa- 
tion with  pathological  changes  in  the  respiratory  passages. 

Acute  Pharyngitis  occurs  as  a  complication  of  certain  of  the  specific 
fevers,  especially  scarlet  fever  and  measles,  but  is  often  primary,  in 
which  case  it  very  commonly  spreads  upward  to  the  nasal  cavities  or 
downward  to  the  respiratory  passages.  It  results  from  the  growth  of 
various  micro-organisms,  cold  and  damp  acting  as  prexlisposing  causes. 

Sjrmptomatology. — Pain  on  swallowing  is  the  most  marked  symptom, 
but  in  young  children  the  condition  often  gives  rise  to  noticeable  con- 
stitutional disturbance.    There  may  be  vomiting  at  the  onset  and  chilli- 


DISEASES  OF   THE  NASOPHARYNX  591 

ness;  the  temperature  rises,  sometimes  to  a  high  level;  there  is  constipa- 
tion, and  the  child  seems  out  of  sorts.  The  pharyngeal  mucous  membrane 
appears  red  and  somewhat  swollen,  the  tonsils  often  sharing  in  the 
inflammation.  After  a  day  or  two  the  symptoms  subside  or  disappear 
after  spreading  in  many  cases  to  the  nose  or  respiratory  passages. 

Treatment.— The  child  should  be  put  to  bed  while  the  fever  lasts,  the 
bowels  moved  with  a  calomel  purge,  and  a  cold  compress  applied  to  the 
throat.  The  diet  should  be  fluid,  and  cold  water  should  be  given  freely 
to  allay  the  sensation  of  dryness  and  thirst.  In  addition,  salicvlate  of 
soda,  0.13  to  0.18  gm.  (2  or  3  gr.),  for  a  child  of  three  years,  with  quinine, 
0.03  gm.  (gr.  ^),  or  phenacetin,  0.13  gm.  (gr.  2),  may  be  given  every  four 
hours,  the  throat  being  sprayed  with  listerine  (1  in  8)  or  with  10  per 
cent,  menthol  in  liquid  paraffin  from  an  oil  atomizer. 

Chronic  Pharyngitis. — This  is  generally  associated  with  an  increase 
of  lymphoid  tissue  in  the  pharyngeal  wall,  a  condition  which  commonly 
accompanies  the  presence  of  adenoid  growths  in  the  nasopharynx,  and 
may  be  congenital,  or  may  result  from  attacks  of  acute  catarrh,  especially 
after  scarlatina  or  measles.  The  disease  gives  rise  to  a  loud,  hard  cough, 
and,  in  addition,  the  symptoms  of  adenoids  with  which  it  is  commonly 
associated  may  be  present.  On  examination  the  pharynx  appears  con- 
gested, with  pale  cushions  of  lymphoid  tissue  projecting  from  its  wall. 

Treatment. — This  consists  in  improving  the  general  health,  removing 
the  adenoid  growths  when  present,  and  painting  the  mucous  membrane 
with  astringent  applications,  such  as  equal  parts  of  liquor  ferri  per- 
chloridi  and  glycerin.  These  methods  failing,  the  lymphoid  tissue  in  the 
posterior  pharyngeal  wall  should,  in  older  children,  be  destroyed  with 
the  galvanocautery. 

FOLLICULAR  TONSILLITIS. 

This  disease  is  rare  in  infancy,  but  not  uncommon  in  older  children, 
especially  where  chronic  enlargement  of  the  tonsils  is  present.  In 
infancy  it  may  be  associated  with  an  acute  influenza  or  a  disturbance  of 
digestion.  The  subjects  of  acute  rheumatism  are  not  infrequently 
attacked,  in  which  case  the  condition  m.ay  be  complicated  by  acute 
endocarditis.  Children  who  are  below  par  and  who  are  allowed  sweets 
and  pastry  are  liable  to  attacks  of  tonsillitis  more  often  than  children 
who  are  given  proper  food. 

Symptomatology. — The  symptoms  are  severe  and  of  sudden  onset. 
Vomiting  may  occur,  though  this  is  a  more  usual  feature  in  cases  of 
diphtheria.  Chilliness  is  common,  or  even  a  rigor,  and  headache  and 
pains  in  the  back  and  limbs  are  generally  complained  of.  The  temper- 
ature rises  rapidly  to  a  high  level,  102°  or  103°  F.  being  common,  and 
the  bowels  are  confined.  The  local  symptoms  are  often  slight.  The  child 
appears  flushed  and  feverisli,  the  tongue  is  coated  and  foul,  and  the 
lymph  nodes  in  the  neck  generally  enlarged.  Both  tonsils  are  affected 
and  are  swollen  and  reddened,  with  plugs  of  yellowish  secretion  pro- 
truding from  the  crypts.    The  symptoms  last  but  a  few  days,  and  the 


592  DISEASES  OF   THE  RESPIRATORY   TRACT 

exudate  rapidly  clears,  though  some  enlargement  of  the  tonsils  may 
remain  for  a  week  or  longer. 

Diagnosis. — Changes  in  the  throat  are  fretjucnt  in  scarlet  fever,  and 
a  diagnosis  from  the  ordinary  follicular  tonsillitis  may  be  difficult  unless 
the  exanthem  is  looked  for.'  Diphtheria  with  memhrane  may  be  mis- 
taken for  tonsillitis,  but  in  the  latter  disease  the  symptoms  of  fever, 
headache,  muscular  pains,  and  lassitude  are  more  decided,  and  arc 
descril)cd  under  the  article  on  Diphtheria  (p.  3S5). 

Treatment.— The  child  should  be  ])ut  to  bed,  and  0.065  gm.  (1  gr.)  of 
calomel  administered.  Quinine  and  sodium  salicylate  are  useful  in  the 
later  stage  of  tonsillitis,  and  especially  so  where  there  is  a  rheumatic 
diathesis.  Phenacetin,  1.3  gm.  (2  gr.)  for  a  child  of  two  or  three 
years,  may  be  given.  In  young  children  local  treatment  may  be  dis- 
pensed with,  but  in  older  children  an  antiseptic  gargle  or  spray,  such 
as  Dobell's  solution,  Sciler's  antiseptic  throat  tablets  in  solution,  or 
listerine  (1  in  S)  should  be  used  every  three  or  four  hours. 


CIRCUMTONSILLAR  ABSCESS. 

Circumtonsillar  Abscess,  or  Quinsy,  is  uncommon  in  childhood.  When 
it  occurs  the  constitutional  symptoms  are  similar  to  those  of  follicular 
tonsillitis,  though  often  less  severe,  while,  in  addition,  marked  local 
symptoms  are  present,  namely,  great  pain  on  swallowing  and  difficulty 
in  unclosing  the  jaws.  The  condition  is  always  unilateral,  and  the 
inflammation  often  starts  behind  the  tonsil,  so  that  this  organ  appears 
thrust  forward  into  the  mouth. 

Treatment. — The  bowels  should  be  well  opened  with  a  calomel  purge 
and  (juininc  and  salicylate  of  soda  given.  Salol  is  recommended  by 
many.  The  diet  must  be  fluid,  but  ample,  and  ice-cream  and  custards 
may  be  of  advantage  when  fluids  are  difficult  to  swallow.  Alcohol  may 
be  given  with  advantage  where  suppuration  seems  inevitable.  When 
pus  has  formed  it  must  be  evacuated  by  means  of  a  guarded  bistoury. 


CHRONIC  HYPERTROPHY  OF  THE  TONSILS. 

This  is  generally  associated  in  children  with  enlargement  of  the  naso- 
pharyngeal tonsil  or  adenoids.  The  hypertrophy  is  in  some  cases  con- 
genital, but  generally  it  arises  from  repeated  attacks  of  tonsillitis  or 
follows  catarrhal  conditions,  influenza,  or  some  one  of  the  specific  fevers 
— diphtheria,  scarlet  fever,  or  measles.  The  symptoms  are  commonly 
associated  with  those  more  important  ones  due  to  adenoid  growths,  but 
when  these  are  eliminated  there  remain  the  "throaty"  voice,  as  if  the 
mouth  were  full  of  food,  dry  cough  in  some  cases,  and  the  tendency  to 
repeated  attacks  of  acute  inflammation. 

Treatment. — This  consists  in  the  removal  of  the  tonsils  with  a  guillo- 
tine, or,  if  operation  is  objected  to  by  the  parents,  their  gradual  reduc- 


DISEASES  OF   THE  NASOPHARYNX  593 

tion  with  the  galvanocautery.  Better  resuks  are  observed  when  the 
child  is  in  the  open  air  and  sunshine,  and  as  the  condition  is  so  often 
associated  with  a  debihtated  state  of  the  system,  hygiene  should  not  be 
overlooked.     Cod-liver  oil  and  iron  are  useful  in  many  cases. 


RETROPHARYNGEAL  ABSCESS. 

Acute  Retropharyngeal  Abscess  is  of  not  uncommon  occurrence  in 
childhood;  tuberculous  abscess,  on  the  other  hand,  is  rare. 

Acute  Retropharyngeal  Abscess.  Etiology.— This  disease  occurs  in 
infants  below  the  age  of  two  years,  and  is  generally  secondary  to  a  pharyn- 
geal or  nasopharyngeal  catarrh.  It  arises  from  infection  of  the  lymph 
nodes  lying  on  either  side  behind  the  pharyngeal  wall. 

In  three  cases  in  which  I  examined  the  pus  aspirated  immediately  before 
operation,  one  contained  the  pneumococcus,  one  a  streptococcus,  and 
the  third  an  organism  of  doubtful  identity;  in  addition,  all  grew  a  few 
colonies  of  a  common  mouth  organism,  a  large  diplococcus  of  gonococcus- 
like  shape. 

Symptomatology. — The  symptom  which  first  calls  attention  to  the  con- 
dition varies  in  different  cases;  it  may  be  dyspnea,  or  swelling  of  the 
lymph  nodes  of  the  neck,  or  nasal  discharge,  accompanied  by  snoring 
during  sleep.  The  dyspnea  is  mainly  inspiratory,  but  may  be  double, 
and  is  worse  in  the  recumbent  posture;  it  not  infrequently  causes  some 
recession  at  the  base  of  the  chest,  which  is  more  marked  when  the  child 
is  excited  or  disturbed.  The  breathing  is  rattling,  and  snoring  or  ster- 
torous; there  is  hard  cough,  which  may  be  paroxysmal,  and  the  voice  is 
nasal,  but  generally  clear.  The  child  appears  ill,  and  the  temperature  is 
raised,  often  to  101°  or  102°  F.  Dysphagia  is  a  common  symptom,  espe- 
cially if  the  swelling  is  low  down  in  the  pharynx.  The  mouth  is  generally 
open,  the  head  inclined  to  one  side  to  relax  the  muscles,  or  sometimes 
retracted.  The  open  mouth  and  evident  distress  are  well  shown  in 
Fig.  130.  The  neck  is  stiff  and  may  appear  generally  enlarged,  or  there 
is  a  swelling  below  one  ear  due  often  to  a  secondary  lymph-node^  infection, 
but  sometimes  to  the  abscess  itself,  which  may  appear  as  a  fluctuating 
swelling  in  the  side  of  the  neck  in  front  of  the  sternomastoid  muscle,  and 
may  extend,  in  some  cases,  from  the  angle  of  the  jaw  nearly  to  the  clavicle. 
On  inspection  and  palpation  of  the  pharynx  a  tense,  globular  swelling  is 
found  on  one  side  of  the  pharyngeal  wall.  To  the  touch  it  is  elastic  in 
the  early  stages,  but  later  fluctuation  is  detected.  The  pharyngeal 
mucous  membrane  is  generally  inflamed  and  often  covered  with  mucus, 
and  it  may  feel  "boggy"  to  the  examining  finger. 

Course.  — After  prompt  surgical  treatment  the  general  condition  rapidly 
improves  and  the  abscess  heals  in  from  one  to  two  weeks,  the  mortality  for 
such  cases  being  very  small.  When  neglected,  or  in  bad  cases  following 
scarlet  fever,  measles,  and  erysipelas,  the  abscess  may  track  down  the 
neck  into  the  mediastinum,  and  the  child  die  with  septic  bronchopneu- 
monia or  occasionally  with  empyema. 


594 


DISEASES  OF   THE  RESPIRATORY   TRACT 


Treatment.— Tlir  abscess  must  bo  promptly  opcMied  as  soon  as  found. 
This  is  best  done  tlirouj^'li  the  i)liarvnii:eal  wall,  either  with  a  guarded 
bistoury  or  by  means  of  a  director,  the  head  being  held  forward  so  that 
the  pus,  generally  but  a  few  drachms  in  ([uantity,  runs  into  the  mouth. 
ruMille  pressure  at  the  sides  of  the  neck  may  help  to  evacuate  it.  After- 
wanl  an  antise])tic  douche  or  sj)ray,  such  a.s  3  per  cent,  resorcin,  or  izal 
1  in  'M)  to  .")()(),  may  be  used  for"'a  few  days.  In  cases  where  a  large 
fluctuating  swelling  appears  in  the  neck,  especially  when  a  septic  source 
for  it  can  be  traced,  it  is  best  opened  and  drained  externally.  Some 
surgeons  ])refer  this  latter  method,  no  matter  whether  the  abscess  be 
subnuicous  or  subcutaneous,  as  they  believe  it  essential  to  clean  out  the 


Cotter's  case  ol  retropharyngeal  abscess  before  operdtion. 


broken-down  lymph  nodes.  The  nature  of  the  operation  must  be  deter- 
mined by  the  character  of  the  case,  but  as  there  is  immediate  relief  from 
a  simple  incision  through  the  pharyngeal  wall,  tliis  operation  can  be  done 
withoiit  delay. 

Tuberculous  Retropharyngeal  Abscess. — Thes(>  cases  are  rare  and 
occur  in  older  children.  They  can  generally  be  diagnosed  from  acute 
abscess  by  their  painless  character,  their  slow  development,  the  age  of 
the  patient,  and  the  fact  that  often  the  swelling  is  less  localized  to  the 
lateral  |)haryngeal  region.  They  arise  from  caseation  of  the  postpharyn- 
geal lymph  nodes,  or,  in  some  cases,  are  due  to  spinal  caries,  in  which 
case  the  symptoms  of  that  disease  will  be  superadded. 


DISEASES  OF   THE  LARYNX  595 

Treatment.— These  abscesses  must  never  be  opened  from  the  pharynx, 
on  account  of  the  danger  of  sepsis.  As  a  rule,  either  the  abscess  itself  or 
some  adjoining  tuberculous  nodes  will  be  found  in  the  side  of  the  neck, 
and  an  operation  must  be  performed  at  this  point,  an  incision  being 
made  along  the  anterior  margin  of  the  sternocleidomastoid,  the  nodes 
removed,  and  the  abscess  drained. 


DISEASES  OF  THE  LARYNX. 
ACUTE  LARYNGITIS. 

Mild  forms  of , this  disease  occur  as  the  result  of  the  inspiration  of  cold 
or  damp  air,  and  may  exist  alone,  or  in  combination  with  nasal  and 
pharyngeal  catarrh,  or  with  tracheobronchitis.  The  voice  is  hoarse  or 
may  be  lost,  and  a  "croupy"  cough  is  present,  but  the  condition  causes 
little  or  no  general  disturbance.  Slore  serious  aspects  of  the  disease  are 
best  described  under  the  term  "laryngitis  stridulosa,"  of  which  slight 
and  severe  varieties  exist.  In  addition,  edematous  laryngitis  claims  a 
few  words  of  description. 

Laryngitis  Stridulosa.— The  slight  attacks  are  commonly  termed 
false  croup,  or  spasmodic  croup,  and  have  generally  been  ascribed  to  a 
spasm  of  the  glottis,  but  there  is  at  least  as  much  evidence  against  as  in 
favor  of  this  theory.  Their  resemblance  to  the  more  severe  form  of 
laryngitis  about  to  be  described  seems  to  me  so  much  closer  than  to  that 
truly  spasmodic  affection  laryngismus  stridulus,  that  I  have  grouped  the 
two  together  under  the  heading  of  Laryngitis  Stridulosa.  The  most  prob- 
able explanation  of  the  attacks  is  a  swelling  of  the  laryngeal  mucous 
membrane,  comparable  to  that  which  so  commonly  obstructs  the  nasal 
fossae  when  the  recumbent  posture  is  assumed  at  the  onset  of  a  nasal 
catarrh. 

Etiology. — The  disease  attacks  children  during  the  first  dentition,  one 
and  a  half  or  two  years  being  a  common  age.  The  condition  very  com- 
monly occurs  at  the  onset  of  measles,  in  some  cases  before  any  symptoms 
of  that  disease  haA^e  appeared,  or  it  follows  in  the  wake  of  measles, 
whooping-cough,  or  influenza. 

Symptomatology. — The  onset  may  be  unexpected,  or  it  may  be 
preceded  by  a  nasal  catarrh,  slight  cough  for  a  day  or  two,  or  in 
some  cases  a  slight  laryngitis  has  been  present  for  a  few  days  before 
the  urgent  symptoms  arise.  As  a  rule,  the  attack  commences  in  the 
night;  the  onset  is  sudden,  with  the  peculiar,  loud,  brassy,  or  "croupy" 
cough,  and  the  breathing  becomes  stridulous  and  difficult.  The  symp- 
toms increase  until  in  many,  cases  the  distress  is  urgent,  and  each 
inspiration  is  accompanied  by  recession  at  the  base  of  the  chest, 
the  end  of  the  sternum,  and  in  the  supraclavicular  and  suprasternal 
fossae.  The  child  appears  anxious  and  very  restless,  the  skin  is  flushed 
and  sweats  freely,  and  some  cyanosis  is  evident.  The  temperature  is 
often  but  little  raised,  and  when  high  this  generally  depends  on  some 


596  DISEASES  OF   THE  RESPIRATORY   TRACT 

accompanying];  pharyngitis.  The  pulse  Is  increased  in  frequency,  but 
the  pulse-respiration  ratio  is  not  disturl^ed.  The  voice  is  generally 
hoarse  and  metallic,  but  may  lx>  natural,  and  stridor  L>  usually  inspira- 
torj'  only,  but  may  accompany  both  inspiration  and  expiration.  On 
examination  the  tongue  is  found  coated,  and  the  fauces  and  tonsils  nearly 
ahvays  reddened;  nasal  catarrh  can  generally  Ix-  observed,  and,  in  cases 
preceding  measles,  conjunctivitis  also.  The  lungs  may  show  a  few 
bronchitic  rales,  but  often  the  laryngeal  stridor  is  the  only  sound  audible. 
The  urgent  symptoms  generally  last  from  one  to  three  days  and  are  sub- 
ject to  paroxysmal  exacerbations,  especially  at  night.  When  they  have 
passed  off  some  amount  of  laryngitis  remains  for  a  week  or  longer.  The 
attack  may  be  so  severe  as  to  necessitate  tracheotomy,  but  this  is  uncom- 
mon. As  a  rule,  the  dyspnea  Ijecomes  gradually  less,  the  stridor  dis- 
appears during  sleep  and  only  returns  with  deep  or  hurried  respiration; 
finally  it  goes  altogether,  leaving  hoarseness  and  cough  for  a  variable 
period. 

Diagnosis.— The  diagnosis  between  laryngeal  obstruction  due  to 
simple  catarrh  and  that  due  to  diphtheria  is  often  very  difficult  until 
the  result  of  a  culture  is  obtainerl.  Moreover,  membranous  laryngitis 
may  occur  apart  from  diphtheria,  and  when  memlirane  Is  discovered 
on  the  tonsils  in  a  case  of  laryngeal  stenosis,  this  may  be  due  to  the 
action  of  streptococci  or  other  organisms.  If  the  palate  is  invaded  it 
is  almost  certainly  diphtheritic.  A  culture  from  the  throat  should  l)e 
taken  in  all  cases,  and  if  membrane  Is  present  films  from  this  should 
Ix'  immediately  examined  if  possible.  In  stridulous  laryngitis  the 
onset  of  the  obstruction  is  usually  sudden,  involving  inspiration  only; 
the  dyspnea  tends  to  be  parox^'smal,  the  voice  is  loud  and  hoarse,  but 
may  be  clear,  and  the  cough  ringing  and  brassy.  In  laryngeal  diph- 
theria, on  the  other  hand,  the  stenosis  is  of  more  gradual  development, 
but  is  progressive,  involving  first  inspiration  only,  but  later  l>oth  inspira- 
tion and  expiration;  the  voice  is  muffled  or  absent.  The  effect  of  treat- 
ment is  often  of  valuable  assistance,  many  of  the  catarrhal  cases  improv- 
ing rapidly  in  the  moist  atmosphere  of  the  steam  tent,  while  this  has  no 
effect  on  the  obstruction  of  diphtheria.  The  temperature  may  be  of  some 
aid,  since  if  it  is  high,  simple  laryngitis  is  more  probable;  whereas,  if  a 
low  temperature  is  present,  with  a  well-marked  throat  inflammation, 
this  is  very  likely  to  be  diphtheritic.  Vomiting  is  common  at  the  onset 
of  diphtheria,  and  the  child,  as  a  rule,  appears  more  ill  and  "poisoned" 
than  in  simple  laryngitis,  which  Is  a  purely  local  process.  Albuminuria 
occurs  in  a  proportion  of  diphtheritic  cases,  but  is  not  present  in  simple 
laryngitis. 

Edematous  Larjmgitis. — This  occurs  in  young  children  as  the  result 
of  sucking  the  sjjout  of  a  l>oiling  kettle,  or  by  drinking  boiling  hot  tea 
or  other  licpiids,  anrl  a  numlx'r  of  cases  have  l>een  recorded.  The  nature 
of  the  condition  is  readily  recognized  by  the  thin  white  pellicle  covering 
the  inside  of  the  mouth  and  leaving  a  raw  surface  when  detached. 
Symptoms  of  laryngeal  stenosis  soon  supervene  and  reach  their  height 
within  twenty-four  hours,  often  rendering  tracheotomy  necessary. 


DISEASES  OF   THE  LARYNX  597 

Treatment.— In  cases  of  even  slight  laryngitis  the  child  should  be  kept 
indoors.  The  room  should  be  warm  and  the  air  moist,  drinking-water 
should  be  freely  given,  and  an  alkaline  mixture  containing  ipecacuanha 
prescribed  for  the  purpose  of  loosening  secretion. 

9;— Vini  ipecacuanhas 0.30  c.c.  (iTlv) 

Sodii  bicarbonatis 0.09  gm.  (gr.  iss) 

Sodii  chloridi 0.03  gm.  (gr!  ss). 

Aquse  chloroformi q.  s.  ad  4.00  c.c.  (5j). 

This  may  be  repeated  every  three  or  four  hours  for  a  child  of  one 
year. 

For  cases  of  so-called  spasmodic  croup,  emetic  doses  of  ipecacuanha 
should  be  given  in  0.6  gm.  (gr.  x)  of  the  powdered  root,  or  4  c.c.  (1 
drachm)  of  the  vinum  every  one-fourth  hour  till  vomiting  is  induced. 
If  no  vomiting  follows  these  large  doses  of  the  drug,  no  harm  but  often 
benefit  accrues  from  them.  At  the  same  time  the  air  around  the  child 
must  be  moistened  by  means  of  a  steam  kettle,  warm  drinks  given,  and 
flannel  or  spongiopiline  wrung  out  of  hot  water  placed  round  the  throat. 

In  cases  of  serious  laryngeal  obstruction,  if  any  doubt  exists  as  to  the 
simple  or  diphtheritic  nature  of  the  condition,  it  is  well  to  administer 
4000  units  of  antitoxin  at  once.  Subsequently  a  calomel  purge  should 
be  given,  and  the  treatment  mentioned  above  pursued,  namely,  a  steam 
tent,  hot  fomentations,  and  emetic  doses  of  ipecacuanha.  In  addition, 
the  inhalation  of  compound  tincture  of  benzoin  from  the  surface  of  hot 
water  may  be  of  assistance.  After  vomiting  has  occurred  the  secretion 
must  be  kept  loose  with  doses  of  vinum  ipecacuanhse,  0.3  to  0.6  c.c. 
(ni,v  to  x),  or  vinum  antimonialis,  0.3  c.c.  ("Iv),  in  a  diaphoretic 
mixture  containing  ammonium  acetate,  1.3  c.c.  ("Ixx)  of  the  liquor, 
every  three  or  four  hours.  The  child  must  remain  in  a  warm  room  until 
the  catarrh  has  subsided,  and  the  normal  conditions  of  life  must  be 
resumed  with  caution.  In  some  cases  intubation  or  tracheotomy  becomes 
necessary  in  spite  of  treatment,  but  if  the  case  is  believed  to  be  simple 
laryngitis  and  the  medical  attendant  can  remain  on  the  spot,  operative 
measures  should  be  postponed  as  long  as  possible. 

The  treatment  of  edema  of  the  larynx  to  be  successful  must  be  ener- 
getic, and  that  which  most  commends  itself  is  the  administration  of 
calomel  after  the  manner  originally  recommended  by  Bevan.  The  drug 
is  given  as  soon  as  a  case  of  the  nature  described  comes  under  observa- 
tion, even  before  laryngitis  arises,  0.06  gm.  (1  gr.)  being  administered 
every  half-hour  till  green  stools  are  passed.  At  the  same  time  cold  com- 
presses must  be  applied  to  the  throat,  and  a  laryngeal  spray  of  picric 
acid  has  been  recommended.  If,  in  spite  of  treatment,  the  stenosis 
becomes  extreme,  tracheotomy  must  be  performed. 

CHRONIC  LARYNGITIS. 

This  is  rare  in  children,  the  symptoms  being  hoarseness  and,  generally, 
some  amount  of  cough.     It  is  commonly  the  outcome  of  a  protracted 


598  DISEASES  OF   THE  RESPIRATORY   TRACT 

acute  catarrh,  or,  in  infants,  is  of  syphilitic  origin.  The  former  cases 
occur  esjx'cially  where  adenoids  are  j)resent,  and  the  removal  of  these 
generally  cures  the  disease;  in  addition,  tiie  use  of  warm  applications  to 
the  throat  and  the  internal  administration  of  potassium  iodide  in  an 
alkaline  mixture  may  l)e  of  benefit,  or,  failing  these,  change  of  air  and 
tonic  remedies  should  he  tried.  Syphilitic  laryngitis  is  not  very  uncom- 
mon in  infancy,  and  its  treatment  is  that  of  the  congenital  disease  it 
accompanies. 

LARYNGISMUS  STRIDULUS. 

This  disease  is  a  pure  neurosis,  depending  for  its  symptoms  on  attacks 
of  spasm,  generally  limited  to  the  glottis,  hut  in  some  cases  passing  on  to 
other  areas,  so  that  a  partial  or  general  convulsive  attack  ensues.  It 
occurs  in  infants  hetween  the  ages  of  six  months  and  two  years  of  age,  is 
most  common  in  male  children,  especially  so  in  those  suffering  from 
rickets,  and  is  often  associated  with  the  presence  of  adenoid  growths. 
The  condition  appears  to  be  most  prevalent  in  the  cold  months  of  the 
year,  possil)ly  l)eeause  the  obstruction  of  adenoids  is  more  marked  at 
th(\s(>  tiuu's. 

Symptomatology. — Th(»  spasm  is  generally  brought  on  by  excitement, 
or  bv  an  attack  of  crying  or  coughing.  It  may  lead  only  to  slight 
inspiratory  difficulty,  giving  rise  to  a  crowing  sound,  resembling  the 
crv  of  a  seagull,  accompanying  several  inspirations.  In  the  more  severe 
attacks  the  head  is  thrown  back,  the  face  becomes  livid,  and  after  a 
long  moment  of  silence  the  breath  is  at  last  drawn  in  again  with  a  loud, 
crowing  sound.  Such  an  attack  may  end  in  loss  of  consciousness,  or 
even  death,  in  which  case  no  sound  is  uttered.  In  other  cases  a  general 
convulsive  seizure  occurs,  or  the  attacks  alternate  with  general  convul- 
sions. Carpo])e<lal  spasm  is  present  in  some  cases  and  persists  between 
the  attacks.  The  attacks  may  be  few  and  far  between,  or  twenty  or  thirty 
may  occur  daily.  The  tendency  to  them  lasts  from  a  few  days  up  to 
mauv  weeks  or  months. 

Treatment. — This  is  directed  toward  improving  the  general  nutrition  of 
the  child,  especially  in  relation  to  the  presence  of  rickets,  in  lowering  the 
nervous  susceptibility,  and  in  removing  or  quieting  any  local  predispos- 
ing cause,  such  as  adenoids,  that  may  be  present.  For  the  first  an  ample 
j)roteid  diet,  attention  to  the  digestive  fimctions,  fresh  air  and  exercise, 
cold  bathing,  and  such  tonics  as  cod-liver  oil  and  iron  or  hypophosphites 
nnist  be  given.  For  the  second  bromides  and  chloral  are  generally  con- 
sidered the  most  reliable  remedies;  the  former  may  be  given  in  doses  of 
0.3  gm.  (5  gr.)  of  the  sodium  salt,  the  latter  in  0.13  gm.  (2  gr.)  doses  to 
a  child  of  one  year,  and  these  may  be  repeated  every  three  or  four  hours 
at  first,  the  intervals  being  afterward  lengthened.  If  adenoid  growths 
are  discovered,  these  may  be  removed,  or,  if  the  infant  is  young,  the 
nasal  catarrh  which  accentuates  their  presence  may  be  kept  in  abeyance 
by  the  use  of  antiseptics,  such  as  1  per  cent,  resorcin,  instilled  into  the 
nostrils,  operation  being  postponed  till  a  later  date.     During  the  attack 


DISEASES  OF   THE  LARYNX  599 

itself  there  is  little  time  for  treatment  the  face  may  be  sprinkled  with 
cold  water,  but  nothing  further  can  be  done;  unless  a  general  convulsive 
seizure  supervene,  in  which  case  chloroform  may  be  administered. 


CONGENITAL  INFANTILE  STRIDOR. 

Pathology. — Various  explanations  of  this  ailment,  both  functional  and 
structural,  have  been  advanced.  Dr.  D.  B.  Lees,  in  a  case  fatal  from 
diphtheria,  found  the  epiglottis  folded  on  itself,  and  the  arytenoepiglottic 
folds  in  contact,  so  that  the  upper  aperture  of  the  larynx  was  greatly 
narrowed.  These  appearances  have  been  confirmed  by  Dr.  G.  A. 
Sutherland  and  Dr.  Lambert  Lack  by  laryngoscopic  examination  dur- 
ing life,  the  thin,  flaccid  folds  bounding  the  aperture  being  observed  to 
fall  together  during  inspiration  and  again  separate  with  expiration.  The 
structural  change  persists  with  growth,  but  the  increasing  rigidity  of  the 
surrounding  parts  serves  more  efficiently  to  keep  the  aperture  patent. 

Symptomatology. — The  symptoms  are  present  from  birth  and  consist 
of  an  inspiratory  croak,  sometimes  likened  by  the  mother  to  the  clucking 
of  a  hen.  In  some  cases  the  croaking  sound  is  audible  during  expiration, 
as  well  as  inspiration.  It  is  absent  during  quiet  breathing,  as  in  sleep, 
but  reappears  when  the  respiration  deepens  on  any  excitement,  or  with 
crying,  coughing,  and  sometimes  in  feeding.  The  cry  is  natural,  and  no 
signs  of  respiratory  obstruction  are  present  during  the  quiet  intervals; 
but  when  the  stridor  is  present  some  inspiratory  recession  of  the  unpro- 
tected parts  of  the  chest  can  be  seen,  and  occasionally  the  alse  nasi  work. 
In  marked  cases  some  amount  of  permanent  chest  deformity  may  be 
set  up.  The  stridor  remains  the  same  or  increases  up  to  the  age  of  nine 
to  twelve  months,  after  which  it  gradually  becomes  less  marked,  and 
ceases  at  eighteen  months  to  two  years  of  age,  but  will  often  reappear 
with  unusual  respiratory  efforts  for  some  years  later. 

Treatment. — The  condition  seldom  leads  to  serious  trouble,  and  from 
its  nature  is  outside  the  bounds  of  drug  treatment.  The  parents  should 
be  reassured,  and  the  general  condition  of  the  child  attended  to,  more 
especially  with  a  view  to  avoiding  the  risks  of  a  superadded  catarrh  of 
the  respiratory  tract.  Tracheotomy  must  be  kept  in  mind  as  the  only 
treatment  available  for  rare  cases  where  suffocation  seems  likely  to  ensue. 


NEW-GROWTHS  OF  THE  LARYNX. 

The  new-growths  include  Papilloma,  Fibroma,  Myxoma,  Chondroma, 
Sarcoma,  and  Epithelioma,  of  which  all  but  the  first  are  very  rare. 

The  Papillomata  are  either  congenital,  or  follow  one  of  the  exan- 
themata in  children  of  about  five  or  six  years  of  age.  Hoarseness  is  the 
first  symptom  to  appear,  and  this  continues  for  a  long  time  before  any 
laryngeal  obstruction  is  brought  about.  The  latter  usually  gives  rise  to 
violent  attacks  of  dyspnea,  in  one  of  which  the  child  may  die  if  no 


GOO 


DISEASES  OF    THE   RESPIRATORY    TRACT 


treatment  is  adopted.  The  growths  are  warty,  with  a  wide  base  of 
attachment,  or  long  and  branching;  they  are  generally  multiple  and 
cover  the  mucous  membrane  between  the  (epiglottis  and  just  below  the 
vocal  cords,  often  hanging  in  thick  tufts,  which  fill  up  the  narrow  space. 


Fig.  131. 


Papilloma  of  the  larynx.    (Elterich.) 


Treatment. — This  consists  in  the  performance  of  tracheotomy,  after 
which  the  growths  separate  and  come  away  in  the  secretions,  the  process 
of  cure  lasting  from  six  months  to  a  year.  If  they  are  removed  by  opera- 
tion recurrence  nearly  always  occurs.  Intubation  is  not  advisable,  as 
the  tube  irritates  the  tumors  and  tends  to  hasten  their  growth. 


CHAPTEE  XXIV. 

THE   LUNGS  IN  EARLY  CHILDHOOD— BRONCHITIS— PULMONARY 
COLLAPSE— BRONCHIAL  ASTHMA. 

THE  LUNGS  IN  EARLY  CHILDHOOD. 

The  lungs  of  the  child  are  both  easier  and  at  the  same  time  more 
difficult  of  examination  than  are  those  of  the  adult — easier  in  that  the 
chest  wall  is  thinner  and  transmits  the  pulmonary  signs  with  more  readi- 
ness; more  difficult  on  account  of  the  emotional  nature  of  the  child, 
which  often  makes  detailed  examination  impossible,  and  also  on  account 
of  the  greater  difficulty  of  interpretation  of  the  signs  discovered.  These 
two  factors  leading  to  difficulty  are  especially  present  during  the  first 
few  years  of  life;  in  older  children  examination  is  generally  easy,  the 
signs  readily  obtained,  and  their  interpretations  more  nearly  that  which 
is  required  in  the  case  of  the  adult. 

The  child's  confidence  should  be  gained,  if  possible,  while  a  history 
is  being  obtained  and  the  general  shape  and  movements  of  the  chest 
observed.  Percussion  should  be  lightly  performed  with  one  finger  only, 
both  because  better  results  are  so  obtained  and  because  the  child  is 
less  likely  to  raise  objection;  in  some  cases  it  is  wiser  to  leave  percussion 
to  the  last.  The  lungs  of  a  crying  child  are  not  very  difficult  to  examine, 
but  those  of  a  screaming,  frightened  child  are  often  impossible.  The 
back  of  the  chest  generally  gives  the  most  important  signs  of  disease, 
and  in  a  difficult  case  may  be  with  advantage  the  part  first  examined, 
The  child  should  be  held  looking  over  the  nurse's  shoulder  or  sitting  on 
a  high  stool  or  table.  The  arms  must  be  drawn  forward  and  the  shoulders 
kept  even.  A  trifling  irregularity  in  position  will  alter  considerably  the 
signs  on  the  two  sides,  both  to  percussion  and  auscultation,  in  the  nor- 
mal chest  of  a  child. 

The  child's  thorax  is  more  nearly  circular  than  that  of  the  adult,  with 

the  result  that  costal  respiration  is'  little  efficient  and  is  largely  replaced 

by  increased  activity  of  the  diaphragm.    As  a  result  of  the  shape  of  the 

chest,  the  lateral  region  is  proportionately  large,  and  must  always  be 

examined  separately  in  the  child,  the  arm  being  raised  above  the  head 

for  that  purpose.     Not  uncommonly  the  earliest  signs  of  a  croupous 

pneumonia  are  by  this  means  discovered  at  the  very  summit  of  the 

axilla.     The  thoracic  walls  are  soft  and  yielding  in  childhood,  more 

especially  when  rickets  are  present.     For  this  reason,  any  respiratory 

obstruction  readily  leads  to  deformity  of  the  chest;  moreover,  collapse 

of  the  lung  is  very  readily  produced  in  parts  where  the  thoracic  suction 

is  feeble. 

( 601 ) 


602  DISEASES  OF   THE  RESPIRATORY   TRACT 

Anatomically,  the  lungs  of  the  child  present  certain  noticeable  differ- 
ences to  those  of  the  adult;  the  air  tubes  are  of  lar<^er  area  in  proportion 
to  the  luni]j  tissue,  which,  perhaj)s,  explains  the  greater  frecpiency  of 
bronchitis  and  bronchopneumonia  in  early  years;  the  interstitial  frame- 
work of  the  lung  is  more  noticeable  than  in  adult  life,  and  the  alveoli 
are  considerably  smaller,  leading  to  the  finer  granulation  of  the  cut  sur- 
face in  crou])ous  ])neumonia. 

With  regard  to  the  pathological  significance  of  various  regions,  the 
apex  is  of  less  importance  than  in  adults,  since  pulmonary  tubercle  does 
not  often  start  at  this  point  in  infancy;  croupous  pneumonia  of  the  upper 
lobes  is  very  common  in  childhood,  and  pulmonary  collapse  occurs  at 
the  base,  in  the  thin  edges,  or  as  a  narrow  band  along  the  posterior 
border  near  the  vertel)ral  bodies. 

In  childhood  the  middle  portion  of  the  lung  has  considerable  path- 
ological significance,  as  it  is  so  commonly  the  seat  of  collapse  or  of 
tubercle  spreading  from  the  lymph  nodcvs  at  its  root.  Localized  j)leural 
effusions  also  may  occur  over  its  surface  and  may  simulate  conditions 
of  cardiac  enlargement.  Careful  examination  of  the  middle  part  of 
the  lung  must,  therefore,  never  be  neglected. 

Certain  warnings  may  be  advantageously  given  with  regard  to  the 
normal  j)ulmonary  signs  of  childhood.  In  the  first  jjlace  it  is  usual, 
especially  in  thin  children,  to  find  bronchovesicular  breathing  in  the 
interscapular  regions  behind,  and  this  bronchial  quality  is,  as  in  adults, 
more  marked  and  more  widely  diffused  at  the  right  apex  than  the  left. 
Secondly,  in  percussing  the  bases  of  the  chest  the  liver  may  give  a  sus- 
picion of  impairment  on  the  right  side,  while  the  stomach  note  is  very 
apt  to  overpower  the  dulness  of  fluid  in  a  small  effusion  at  the  left  base. 
Thirdly,  loud  sounds,  such  as  bronchial  breathing  and  loud  friction 
sounds,  are  readily  transmitted  across  the  chest  from  one  side  to  the 
other,  so  as  to  appear  present  at  both.  They  may  also  be  heard  over 
the  upper  area  of  the  abdomen.  Lastly,  a  cracked-pot  sound  may  often 
be  obtained  on  percussion  over  the  front  of  the  chest  in  an  infant,  par- 
ticularly when  crying. 

The  thoracic  lymph  nodes  are  of  great  im])ortance  in  the  early  years 
of  life,  owing  to  the  frequency  with  which  they  are  the  primary  focus 
from  which  tuberculosis  of  the  lung  arises.  They  cannot  be  themselves 
examined  during  life,  but  signs  of  consolidation  in  the  intrascapular 
region  may  sometimes  point  to  a  spread  of  tubercle  from  them,  and  the 
presence  of  enlarged  tracheal  nodes  beneath  the  manubrium  may  con- 
firm the  diagnosis  in  a  case  of  l)ronchopneumonia  of  doubtful  nature. 

ACUTE  BRONCHITIS. 

An  inflammation  of  the  bronchial  tubes  is  one  of  the  commonest  mala- 
dies of  childhood,  and,  though  often  insignificant  in  itself,  it  must  always 
be  treated  with  respect,  on  account  of  its  relationship  to  more  serious 
diseases.  Prompt  treatment  is  always  needed,  both  immediate,  to  avert 
the  danger  of  bronchopneumonia  and  pulmonary  collapse,  and  subse- 


ACUTE    BRONCHITIS  603 

quent,  to  prevent  future  attacks  and  the  risk  of  a  chronic  susceptibihty 


arisino;. 


Etiology.— Bronchitis  is  most  common  in  the  cokl  months  of  the  year. 
The  exciting  cause  is  some  variety  of  micro-organism,  differing  in  nature 
according  to  the  origin  of  the  infection.  The  organisms  connected  with 
the  infective  fevers,  many  of  which  have  bronchitis  as  an  accompaniment, 
are  doubtless  causative  in  this  respect — influenza,  whooping-couo-h,' 
nieasles,  and  many  others — in  some  of  which  the  organism  is  recog- 
nized, and  in  some  its  presence  merely  assumed.  In  addition,  the 
primary  cases  are  due  to  bacteria,  probably  of  more  than  one  species, 
derived  from  the  nose  and  pharynx,  and  any  organism  causing  catarrh 
of  these  chambers  may  also  cause  catarrh  of  the  bronchial  tubes. 

The  most  important  of  general  'predisposing  causes  is  what  may  be 
termed  "injudicious  coddling."  Perhaps  the  child  has  already  had  an 
attack  of  bronchitis  and  the  parents  greatly  fear  a  return  of  the  trouble. 
The  result  is  that  a  "hot-house"  system  is  instituted  whereby  the  child's 
susceptibility  is  greatly  increased  by  overheated,  stuffy  rooms,  an 
excess  of  heavy  clothing,  causing  the  skin  to  remain  moist  and  sweating, 
and  great  deficiency  of  fresh  air  and  exercise.  Under  these  conditions 
the  smallest  exposure  will  cause  a  fresh  catarrh  and,  thereafter,  caution 
is  redoubled  with  further  disastrous  results.  Such  children  must  be 
gradually  acclimatized  to  more  healthy  conditions  so  that  their  abnormal 
susceptibility  may  be  reduced. 

In  infants  two  common  conditions  are  often  the  starting  point  of 
bronchitis,  namely,  teething  and  attacks  of  diarrhea.  The  former 
probably  acts  by  increasing  susceptibility  through  the  presence  of  a 
certain  amount  of  catarrh  and  pyrexia  which  seem  incidental  to  the 
process;  in  the  latter  one  might  well  suppose  that  some  absorption  of 
toxins  from  the  intestinal  tract  was  responsible,  but  the  same  results 
may  sometimes  be  observed  from  free  purgation  with  drugs,  and  I 
cannot  help  attributing  it  also  to  a  heightening  of  susceptibility. 

The  condition  commonly  known  as  chill  is  perhaps  best  described 
as  an  "immediate"  predisposing  cause  owing  to  its  close  relation  to  the 
bronchitic  attack.  It  is  induced  by  general  or  local  change  of  surface 
temperature,  especially  in  certain  susceptible  individuals,  and  is  prob- 
ably a  vasomotor  phenomenon.  It  has  been  experimentally  shown  that 
the  application  of  cold  to  the  skin  is  followed  by  a  reflex  contraction 
of  the  tracheal  vessels,  followed  by  congestion  and  an  increased  flow 
of  mucus.  This  is  the  condition  which  probably  forms  the  starting 
point  of  many  bronchitic  attacks  by  offering  a  convenient  nidus  for 
local  infection. 

Of  local  predisposing  causes,  adenoid  growths  are  the  most  important, 
acting,  probably,  by  keeping  a  growth  of  organisms  always  handy  on 
the  catarrhal  surfaces  of  the  nasopharynx,  but  also  through  the  unhealthy 
habit  of  mouth-breathing,  whereby  the  air  enters  the  passages  in  an 
un warmed  and  unfiltered  condition. 

Pathology. — The  bronchial  mucous  membranes  become  swollen  and 
injected,  and  the  secretion,  at  first  diminished  in  quantity,  soon  becomes 


604  DISEASES  OF    THE   RESPIRATORY    TRACT 

increased,  passing  through  the  stages  of  serum  and  mucoserum  to 
mucopus  as  the  (hsease  advances.  The  mucous  membrane  only  is 
attacked  at  first,  but  if  the  inflammation  continues  the  wliole  thickness 
of  the  bronchial  wall  may  be  involved,  leading  to  a  dilatation  of  its 
channel.  When  the  smaller  tubes  are  affected,  plugging  of  their  lumen 
readily  occurs,  leading  to  the  formation  of  areas  of  collapse,  and  these 
to  areas  of  compensatory  emphysema.  Collaj)se  is  found,  especially  in 
the  lungs  of  infants,  generally  as  shallow  areas  down  their  posterior 
surfaces. 

Symptomatology. — Bronchitis  may  be  divided  up  for  convenience 
under  three  iicadings,  though  the  division  must  be  to  a  large  extent 
arbitrary. 

1.  Tracheobronchitis,  in  which  the  trachea  and  large  tubes  are  affected, 
giving  rise  to  cough,  but  to  little  or  no  constitutional  disturbance.  The 
process  generally  spreads  down  from  the  pharynx  or  nasal  cavities  and, 
for  signs,  either  a  few  nlles  are  heard  at  the  root  of  the  lungs  or  nothing 
is  found  on  examination. 

2.  Bronchitis  of  the  medium  tubes,  which  comprises  the  common  cases 
of  acute  and  severe  bronchitis  with  constitutional  symptoms. 

3.  Capillary  bronchitis,  a  widespread  inflammation  of  the  finest  tubes 
extending  into  the  lobular  bronchioles  and  accompanied,  in  most  cases, 
by  inflammatory  changes  in  the  lung  alveoli. 

In  the  slight  cases  of  bronchitis  where  only  the  larger  tubes  are 
involved  the  general  health  may  remain  unaffected,  and,  beyond  some 
cough,  no  discomfort  may  occur.  In  more  marked  cases  the  temperature 
may  be  somewhat  raised,  and  the  cough  hard  and  distressing  with  some 
soreness  under  the  sternum. 

In  severe  cases  of  bronchitis  the  symptoms  are  often  of  sudden  onset, 
or  sometimes  slight  cough  is  noticed  for  a  day  or  two,  and  then  the 
condition  gets  rapidly  worse,  as  at  the  onset  of  many  cases  of  broncho- 
pneumonia. Vomiting  may  be  an  initial  symptom,  a  hard  cough 
develops,  the  child  is  feverish,  restless,  and  refuses  food,  and  the  breath- 
ing becomes  rapid  and  distressed.  Pain  under  the  sternum  or  in  the 
epigastrium  is  described  by  older  children,  and  also  headache  in  many 
cases. 

The  child  appears  flushed  and  feverish,  with  a  warm,  moist,  or 
sweating  skin;  the  conjunctivae  maybe  injected  and  watery,  and  nasal 
discharge  is  often  noticeable.  The  breathing  is  rapid  and  difficult,  the 
aliie  nasi  are  active,  and  the  child  gives  vent  to  a  hacking  cough  at 
intervals.  The  tongue  is  moist  and  coated,  the  pharynx  injected,  the 
temperature  raised,  and  the  pulse  rapid  and  full,  perhaps  140  per 
minute  in  a  child  of  one  year.  The  attack  lasts  from  five  or  six  days 
up  to  ten  days  or  a  fortnight  in  most  cases. 

The  cough  is  dry  and  hacking  at  first;  later  it  becomes  looser, choking, 
and  sometimes  spasmodic.  It  is  generally  painful  at  the  beginning, 
and  may  cause  crying  or  attacks  of  screaming  in  young  children.  Chil- 
dren do  not  expectorate  their  phlegm,  but  occasionally  some  is  brought 
up  with  vomiting,  more  commonly  in  the  later  stages,  when  it  is  puru- 


ACUTE    BRONCHITIS 


605 


lent   and   more   abundant;   at  the  beginning  it  is  thick,  viscid,  and 
tenacious. 

^  In  young  children  a  high  temperature  is  generally  found  at  the  begin- 
ning, and  the  height  to  which  this  may  rise  is  simple  bronchitis  is,  I 
think,  not  always  sufficiently  realized.  A  temperature  of  102°  or 
103°  F.  is  not  at  all  uncommonly  seen  during  the  first  few  days — thus 
a  child  of  ten  months  had  a  temperature  of  103.8°  F.  for  the  first  three 
nights,  the  attack  was  finished  by  the  fifth  day;  another  child  of  two 
years  and  four  months  had  a  temperature  of  103°  F.  for  three  nio-hts, 
with  no  subsequent  rise.  These  cases  showed  no  signs  of  teething,  but 
when  this  accompanies  bronchitis  the  temperature  is  usually  high,  often 
103°  F.  or  more,  as  in  a  child  of  one  year  and  three  months  in  whom  the 
temperature  rose  to  105°  F.  on  one  occasion.  A  persistence  of  tem- 
perature after  three  or  four  days  is  significant  of  further  inflamma- 
tion. 

The  point  about  the  high  fever  in  bronchitis  is  its  short  duration; 
it  rarely  lasts  more  than  three  or  four  days  and  thereafter  the  temper- 
ature is  much  lower,  or  normal.  Occasionally  it  remains  as  high  as 
101°  to  103°  F.  for  a  week  or  even  more.  The  temperature  usually  shows 
considerable  fluctuations,  as  in  bronchopneumonia,  and  is  very  irregular 
in  its  course,  being  high  in  the  evening  and  low  in  the  early  morning 
hours,  though  occasionally  the  inverse  type  is  observed,  high  in  the 
morning  and  low  at  night.  In  older  children,  and  in  the  slighter  attacks 
of  young  children,  there  is  but  little  fever,  100°  F.  being  a  common  tem- 
perature. 

When  the  larger  tubes  only  are  affected  there  is  no  respiratory  distress, 
unless,  in  young  children,  the  secretion  be  drawn  into  the  finer  branches. 
In  severe  attacks  where  the  smaller  tubes  are  involved  the  face  is  con- 
gested and  cyanosed,  the  breathing  much  labored,  and  there  may  be 
considerable  dyspnea.  In  such  a  case  the  respirations  are  rapid  and 
gasping,  the  alse  nasi  dilate  actively,  and  the  pulse-respiration  ratio  is 
disturbed,  an  alteration  to  3  :  1  being  common,  but  not  often  greatly 
exceeded.     There  may  be  slight  orthopnea. 

The  skin  is  hot  and  often  dry  at  the  height  of  the  fever,  but  there 
is  usually  free  sweating  in  the  early  morning  hours  when  the  temperature 
is  low,  and  often  at  other  times  also.  This  is  most  marked,  as  a  rule, 
about  the  head  and  face.  While  fever  is  present  the  skin  over  the  trunk 
often  appears  flushed  when  exposed,  with  a  slight  punctiform  accent- 
uation, due,  probably,  to  the  activity  of  the  sweat  glands. 

Bronchitis  is  often  preceded  or  accompanied  by  catarrh  of  other 
mucous  membranes.  Nasal  discharge  is  often  noticed,  and  pharyngitis 
is  not  uncommon.  These  are  especially  to  be  observed  when  adenoids 
are  present  or  when  influenza  is  prevalent.  In  some  cases  there  is 
conjunctivitis,  and  a  suspicion  of  measles  may  be  entertained  until  the 
fourth  day  is  passed  and  no  rash  appears.  Aphthous  stomatitis  is 
observed  in  some  cases. 

In  older  children  there  may  be  constipation;  in  infants  there  is  very 
often  some  diarrhea  throughout  the  attack,  and  sometimes  preceding  it. 


GOG  DISEASES  OF   THE   RESPIUATORY    TRACT 

Physical  Exainiuuiion.—Yw  a  st'vrrc  attack  the  t-lu'st  takes  the 
position  of  inspiration  owinj^  to  hyperinfhition  of  the  air  eells,  the  result 
of  dyspnea;  therewith  is  often  seen  some  inspiratory  recession  in  the 
infraniannnary  region  owing  to  insufficient  air  entry  at  the  bases,  and 
this  may  become  very  marked,  especially  in  cases  associated  with 
rickets.  On  palpation  the  hand  placi'd  upon  the  chest  may  often  detect 
rales  in  the  lungs;  the  movements  are  observed  to  be  ecpial  on  the  two 
sides  unless  in  cases  where  there  is  considerable  collapse  at  one  base. 
Over  the  front  of  the  chest  the  'percussion  note  may  be  somewhat  high- 
pitched,  and  occasionally  some  dulness  over  the  middle  lobe  due  to 
temj)orary  collapse  is  found.  Behind  the  note  may  be  normal,  but  in 
infants  there  is  often  slight  impairment  at  the  bases  caused  by  areas  of 
superficial  collapse,  and  sometimes  such  areas  may  also  be  made  out 
over  the  rest  of  the  lungs  by  light  percussion. 

Auscultation  shows  riMes  of  various  sorts  and  sizes  scattered  over 
the  lungs.  Thus,  there  may  be  abundant  fine,  moist  rfdes  audible  both 
with  inspiration  and  expiration,  with,  perhaps,  a  few  sibili  here  and 
there;  or  the  rales  may  be  audible  only,  or  mostly,  at  the  end  of  inspira- 
tion; or  at  one  ])()int  the  r;iles  are  bubbling  in  character;  or  there  may 
be  only  whee/y,  dry  sounds  acc()m|)ani(Ml  by  croaking  and  purring 
sounds  during  expiration.  As  a  rul(>,  the  rfdes  are  most  abundant  at 
the  bases  behind  where  they  are  mostly  moist,  the  dry  sounds  being 
generally  heard  at  the  roots  and  upper  ])arts  of  the  lungs;  the  moist 
sounds  are  mainly  formed  in  the  smaller,  and  the  dry  sounds  in  the 
larger  tubes,  and  both  are  generally  present  in  the  same  case.  The 
stage  at  which  a  case  is  examined  does  not  determine  the  nature  of  rale 
that  will  be  audible;  moist  niles  are  often  heard  a  day  or  two  after  the 
onset  and  remain  to  the  end,  when  they  and  the  dry  sounds  in  the 
larger  tubes  all  clear  uj)  togetluM'. 

'I'he  l)reatli  sounds  are  vesicular  all  over,  though  in  front,  over  the 
emphysematous  parts,  they  nuiy  be  harsher  than  usual,  and  expiration 
somewhat  prolonged.  Behind,  the  breath  sounds  may  be  feebler  at  the 
base  over  the  collapsed  portions,  but  often  the  collapse  is  so  su])erficial 
as  to  cause  no  diminution  of  the  breath  sounds,  though  the  percussion 
note  is  nniflled.  In  exceptional  cases  an  area  of  collapse  may  extend 
sufficiently  ileep  to  give  rise  to  bronchial  breathing  at  some  spot  near 
the  base,  and  in  such  a  case  the  general  symptoms  and  course  must  be 
taken  into  consideration  to  exclude  infianimatorv  consolidation.  The 
vocal  resonance  is  not  altered  over  the  lung  in  l)ronchitis. 

(\\PILLAUY  BiioNCiTiTis  is  an  inflammation  of  the  finest  tubes  through- 
out the  lungs,  the  process  passing  on  in  most  cases  into  the  alveoli,  so  that 
there  is  present  at  the  same  time  an  actual  or  potential  broncho- 
pneumonia. In  the  most  acute  cases  death  ensues  before  this  disease 
has  had  time  to  become  manifest.  The  symptoms  are  those  of  a  bron- 
chitis of  exceptional  severity;  the  child  sits  up  in  bed  with  the  most 
urgent  dyspnea,  and  in  bad  cases  cannot  afford  breath  either  for  feeding 
or  crying.  The  surface  is  cold,  cyanosed,  and  covered  with  sweat;  the 
thorax  appears  prominent  above  from  emphysema,  with  collapse  and 


ACUTE   BRONCHITIS  607 

corresponding  recession  at  the  bases.  Rales  are  audible  over  the  lungs, 
and  the  air  entry  is  very  deficient  below.  The  condition  is  very  fatal, 
the  child  becoming  drowsy  from  carbonic  acid  poisoning,  and  passing 
rapidly  to  coma  and  death. 

Diagnosis. — This  is  discussed  under  the  heading  of  Bronchopneumonia 
(p.  626),  the  disease  with  which  bronchitis  is  most  hable  to  be  con- 
founded, and  with  which  it  may  be  associated. 

Prognosis. — Acute  bronchitis  of  the  larger  and  medium  tubes  is  very 
rarely  fatal,  apart  from  the  advent  of  pulmonary  collapse  or  broncho- 
pneumonia in  infancy.  The  disease,  as  a  rule,  proceeds  to  complete 
recovery,  leaving  behind,  at  most,  some  temporary  emphysema  and  a 
susceptibility  to  bronchial  catarrh.  Capillary  bronchitis,  on  the  other 
hand,  is  very  fatal,  death  being  due  to  asphyxia  often  before  the  lesions 
of  bronchopneumonia  have  had  time  to  develop. 

Treatment.  Immediate  Treatment. — The  child  should  be  put  to  bed 
in  a  room  well  warmed  by  an  open  fire,  and  efficiently  ventilated  either 
by  a  window  opened  at  the  top  or  by  some  other  means.  A  stuffy,  ill- 
ventilated  room  probably  increases  the  risk  of  bronchopneumonia;  the 
bed  should  stand  away  from  the  corner  of  the  room;  the  temperature 
should  be  between  60°  and  65°  F.,  and  the  air  kept  moistened  by  a 
bronchitis  kettle  or  by  wet  towels  kept  hanging  before  the  fire.  At  the 
onset,  in  a  severe  attack,  a  calomel  purge  should  be  given,  0.06  gm. 
(1  gr.)  to  a  child  of  two  years,  or  0.03  gm.  ( j  gr.)  combined  with  0.06 
to  0.13  gm.  (1  or  2  gr.)  of  compound  scammony  powder  to  a  child  below 
this  age.  These  can  be  dispensed  with  in  a  slight  attack.  In  the  early 
stages,  when  the  cough  is  hard  and  dry,  the  simple  expectorants,  ipecac- 
uanha or  antimony,  are  of  value  to  thin  the  secretion,  and  the  following 
mixture  may  be  prescribed  for  a  child  of  one  year,  to  be  administered 
every  three  or  four  hours: 

Jt— Vini  ipecacuanliEe 0  3  c.c.  QMy)- 

(or)  Viui  antimonialis 0.2  "  (Ifliij). 

Spiritus  tetheris  iiitrosi 0.3  "  (ITlv). 

Liquoris  ammonii  acetatis 1.0  "  (lllxv). 

Aq.  chloroformi q.  s.  ad  4.0  "  (3j).— M. 

If  the  child  is  very  restless  and  ill,  and  especially  if  there  is  diarrhea, 
a  few  minims  of  brandy  may  be  added  with  advantage,  but  the  sedative 
effect  of  brandy  must  not  be  overlooked  where  cough  is  needed  to  clear 
the  tubes  of  copious  secretion. 

When  the  secretion  in  the  tubes  is  free,  as  indicated  by  the  changed 
character  of  the  cough,  and  not  until  then,  the  stimulating  expectorants, 
ammonia,  squill,  and  senega,  may  be  given  to  help  expulsion  and  control 
secretion;  0.03  gm.  (j  gr.)  doses  of  ammonium  carbonate  may  be 
given  to  a  child  of  one  year,  as  in  the  following  prescription : 

{t— Ammonii  carbonatis       .        . 0.03  gm.  (gr.J^). 

Spiritus  chloroformi 0.07  c.c  (ITIJ). 

Infusi  senegse 2  00  "  (5>2). 

Aq q.  s.  ad  4.00  "  (3j). 

The  object  of  treatment  is  to  liquefy  the  secretion,  and  then  to  check 
its  formation. 


608  DISEASES  OF   THE  RESPIRATORY   TRACT 

In  cases  where  the  tubes  are  blocked  with  secretion  which  cannot  be 
expectorated,  Icadinf^  to  deficient  aeration  of  tlie  blood,  an  emetic  must 
be  given.  The  most  convenient  is  ipecacuaidia,  either  the  powder  in 
0.7  gm.  (10  gr.)  doses,  or  the  wine,  4  c.c.  (1  dr.)  every  one-fourth  hour 
until  vomiting  is  induced;  this  may  be  aided,  if  necessary,  by  tickling 
the  fauces  with  a  feather,  or  by  the  passage  of  the  stomach  tube. 

Prophijladic  Trcatmcnt.^U  the  health  has  been  impaired  by  the 
acute  attack,  change  of  air,  if  the  time  of  year  allow  it,  to  a  dry  place 
away  from  smoke  and  dust  is  a  good  beginning;  but  if  it  is  a  cold  season 
of  the  year,  as  so  often  happens,  this  is  not  always  advisable.  The 
child  must  first  be  gradually  acclimatized  to  cooler  rooms  and  the 
ordinarv  air  of  th(>  house,  care  being  taken  that  he  is  lightly  but  warmly 
clothed'with  flannel  next  the  skin,  the  legs  completely  covered,  and  the 
feet  kept  warm. 

The  child's  bath  should  be  given  on  rising  in  the  morning  instead 
of  at  night;  at  the  latter  time  the  skin  may  be  rubbed  briskly  with 
a  dry  towel  on  going  to  bed.  He  should  stand  in  hot  water  and  be 
rapidly  soaped  all  over,  at  the  end  a  sponge  full  of  cool  water  should  be 
emptied  down  chest  and  back,  and  he  should  be  taken  out  into  a  rough 
towel,  and  dried  smartly  until  the  skin  is  red  and  warm.  After  a  time 
the  cool  water  can  be  rendered  cooler  and  cooler  until  it  is  used  at  the 
room  temperature,  but  for  infants  under  eighteen  months  of  age  70°  F. 
or  thereabouts  is  generally  cool  enough,  and  lower  temperatures  may 
be  depressing.  If  no  reaction  follows  the  cold  douche  it  is  evidence 
that  the  child  cannot  stand  it  at  the  temperature  given,  and  it  must  be 
suspended  for  a  time.  It  is  always  better  to  begin  this  treatment  in 
the  summer  weather;  the  cold  ilouche  can  then  generally  be  maintained 
throughout  the  winter  months  with  advantage.  The  whole  bath  should 
not  take  above  one  and  a  half  to  two  minutes  from  the  moment  the 
child  steps  in  to  the  time  he  is  taken  out  to  be  rubbed  dry. 

The  living-rooms  must  not  be  kept  overheated,  and  efficient  ventilation 
must  be  secured.  Except  in  very  cold  weather  the  window  should  be 
kept  open  at  the  top,  and  in  winter  the  "poor 'man's  ventilator,"  or 
window  board,  is  a  very  efficient  mechanism,  the  lower  sash  being  raised 
on  a  piece  of  wood  which  fits  the  window  below,  and  allows  a  stream 
of  air  to  enter  between  the  sashes  above.  In  French  windows  a  venti- 
lating pane  is  most  convenient.  The  child  must  be  out-of-doors  as  much 
as  possible,  a  brisk  run  being  permissible  in  nearly  all  kinds  of  weather 
if  the  best  time  of  the  day  be  chosen.  If  confinement  to  the  house 
seems  imperative  the  child  should  leave  his  nursery  at  least  twice  in  the 
day,  when  the  windows  must  be  thrown  wide  open  for  efficient  airing. 
He  must  be  given  as  much  sunshine  as  the  season  of  year  permits. 

Wet  shoes  and  stockings  or  damp  clothing  must  be  changed  at  once 
and  dry  substituted,  the  feet  being  rubbed  with  a  rough  towel  if  cold; 
cold  feet  are  a  common  cause  of  catarrh  of  mucous  membranes,  and 
must  be  avoided.  The  foolish  fashion  of  bare  feet  and  sandals  is 
responsible  for  many  inflammatory  attacks  of  mucous  membranes,  and 
is  to  be  strongly  deprecated  in  a  cold  and  changeable  climate,    Cod-liver 


CHRONIC  BROXCHITIS  609 

oil  will  be  of  value  in  increasing  the  nutrition  of  the  children,  but  no 
more  good  is  to  be  expected  from  it  than  from  plenty  of  nutritious  food. 
The  desiderata,  when  all  is  said  and  done,  are  warm  but  light  cloth- 
ing and  plenty  of  fresh  air  and  exercise. 


CHRONIC  BRONCHITIS. 

In  cases  where  catarrh  of  the  bronchial  tubes  is  neglected,  and  also 
where  an  unnatural  susceptibility  exists  or  is  fostered  by  injudicious 
management,  the  condition  termed  Chronic  Bronchitis  is  set  up.  The 
mucous  membrane  and  its  underlying  structures  become  permanently 
damaged  and  thickened,  and  the  secretion  is  excessive  at  all  times, 
giving  rise  to  the  cough  which  leads  to  its  expectoration.  Often  a  less 
marked  condition  than  this  exists,  the  changes  being  less  permanent, 
so  that  the  cough  disappears  in  the  warm  summer  weather,  to  return 
again  on  the  slightest  provocation,  the  child  being  subject  to  exacer- 
bations at  various  intervals.  Sometimes  the  cough  occurs  only  during 
the  winter  months,  often  in  acute  phases,  lasting  three  or  four  weeks, 
with  intervals  of  six  weeks  or  two  months  between.  Chronic  emphysema 
is  generally  set  up  and  may  be  much  or  little ;  if  the  former  it  adds  both 
to  the  present  distress  and  to  the  future  susceptibility,  and  in  such  case 
the  breath  is  short  on  exertion,  the  face  congested,  and  the  chest  barrel- 
shaped.    As  a  rule,  the  emphysema  is  moderate  in  amount. 

Symptomatology. — During  the  acute  attacks  the  conditions  may  be 
similar  to  those  already  described  under  Acute  Bronchitis,  save  that  to 
them  are  added  the  chronic  disabilities  of  the  affected  organs.  The 
inflation  of  the  lungs  is  seen  to  be  excessive,  the  heart  unusually  embar- 
rassed, and,  in  rare  cases,  a  tendency  to  finger-clubbing  is  noted.  As 
a  rule,  the  acute  attack  is  rather  a  subacute  exacerbation  than  a  definite 
acute  bronchitis,  and  the  temperature  is  then  but  little  or  not  at  all 
raised.  In  cases  where  emphysema  is  marked  some  bronchial  spasm 
not  uncommonly  accompanies  the  inflammatory  change. 

Treatment. — The  treatment  in  the  acute  exacerbation  is  similar  to  that 
of  acute  bronchitis.  When  this  is  past,  the  danger  of  recurrence  must 
be  warded  off.  The  child  should  winter  in  a  warm  climate,  some  dry, 
sunny  spot  being  chosen,  when  possible,  where  he  can  be  out  of  doors  a 
great  part  of  the  day  without  danger  of  chilling.  In  such  favorable  sur- 
roundings there  is  hope,  in  childhood,  that  the  mucous  membranes  will 
gain  in  resisting  powers  and  the  susceptibility  be  outgrown.  If  such 
change  cannot  be  had  the  best  must  be  made  of  the  climate  where  the 
child  lives,  the  child  getting  out-of-doors  whenever  the  weather  permits. 
A  judicious  and  carefully  graduated  system  of  increasing  the  child's 
resistance  must  be  carried  out  on  the  lines  suggested  under  the  heading 
of  Prophylaxis  in  Acute  Bronchitis.  In  addition,  nourishing  food,  espe- 
cially butter,  cream,  and  eggs,  healthy  exercise,  with  precautions  to  avoid 
chills,  and,  at  intervals,  a  course  of  tonics  such  as  cod-liver  oil  with  iron 
and  creosote,  or  the  hypophosphites  of  lime  and  soda,  are  necessary  to 
39 


(310  DISEASES  OF    THE   RESPIRATORY    TRACT 

aid  nutrition  and  rnable  the  patient  to  outgrow  liis  susecptibility.  If 
tile  elnld  has  adenoids  or  enhir<;ed  tonsils  they  .should  be  removed  as 
a  preliminary  to  all  other  treatment. 


PLASTIC  BRONCHITIS. 

This  is  a  rare  disease  whieh  is  also  described  under  the  name  of 
Fibrinous  Bronchitis.  It  may  occur  at  any  period  of  life,  many  of  the 
cases  commencing  in  childhood. 

Pathology. — This  is  not  understood,  l)ut  it  forms  a  clinical  entity 
apart  from  those  cases  where  false  membranes  have  been  found  as  a 
result  of  irritating  vapors,  or  associated  with  such  diseases  as  diphtheria, 
phthisis,  pneumonia,  and  certain  of  the  infective  fevers. 

The  Casts. — Large,  round  masses,  yellowish  green  in  color,  are  expec- 
torated, which  when  placed  in  water  separate  into  mucopus  and  the 
fibrinous  cast  of  the  tubes.  This  consists  of  a  hollow  stem  generally 
about  the  diameter  of  a  goose-cpiill,  branching  out  into  an  arborescent 
arrangement  representing  the  bronchi  down  to  their  finest  ramifications. 
On  other  occasions  fragments  only  of  such  casts  are  expectorated. 
Their  color  is  grayish  white,  and  they  consist  of  a  tough  membrane 
whose  main  constituent  is  fibrin. 

Symptomatology. — The  attacks  recur  at  intervals  varying  from  a  few 
days  to  many  years,  and  the  liability  to  them  may  continue  for  years, 
or  throughout  life.  The  onset  may  be  with  vomiting,  and  cough  soon 
follows,  accompanied  in  some  cases  by  pain  in  the  side.  The  cough 
is  hard  and  dry,  an<l,  if  the  fibrinous  exudation  affects  a  large  area  of 
the  bronchial  tree,  there  may  be  considerable  dyspnea,  which  continues 
until  the  membranes  are  expectorated.  The  respirations  are  rapid 
during  the  exudation  period,  the  pulse-respiration  ratio  being  disturbed 
to  .3  : 1  or  even  2^  :  1  as  in  pneumonia.  Many  days  pass  before  the 
casts  separate,  though  some  mucus  may  be  expectorated,  and  after 
four  days  to  one  week  or  ten  days,  the  large,  round  masses  appear 
which  contain  the  fibrinous  plugs.  Immediately  thereafter  the  patient 
is  easier,  the  dyspnea  departs,  and  the  temperature,  which  was  high, 
drops  to  normal,  to  rise  again  with  the  formation  of  fresh  casts,  a  process 
which  continues  for  a  variable  period  up  to  a  fortnight  or  more.  Relapse 
may  occur  with  the  involvement  of  fresh  areas  of  the  bronchial  tree 
before  the  process  quiets  down. 

In  cases  of  extensive  exudation  the  pln/sical  signs  are  marked,  as  in 
a  child,  aged  six  years,  whom  I  have  had  the  opportunity  of  observing 
during  two  attacks.  In  the  first  attack  there  appeared  dulncss  at  the 
left  base  up  to  the  scapular  angle,  with  feeble  breath  sounds  and 
diminution  of  vocal  resonance,  but  no  added  sounds — signs,  indeed,  of 
pulmonary  collapse.  Later  a  friction  rub  developed  over  this  area, 
and,  when  the  casts  were  loosened,  some  bronchial  breathing  with 
increase  of  vocal  resonance,  and  sharp  crepitations.  In  the  second 
attack  two  months  later  the  same  signs  appeared  in  the  same  situation, 


PULMONARY    COLLAPSE 


611 


and  in  a  relapse  which  took  place  the  right  apex  was  attacked.  A  few 
rales  generally  appear  after  the  membranes  are  loosened,  and  continue 
as  long  as  any  expectoration  remains. 

Prognosis. — The  disease  is  not  dangerous  to  life,  though  the  liability 
to  attacks  may  last  for  years. 

Treatment. — The  treatment  is  only  expectant,  since  nothing  is  known 
to  influence  the  disease.  Biermer  recommended  the  inhalation  of  a 
lime-water  spray  on  account  of  the  power  of  this  drug,  and  of  alkalies, 
generally,  to  dissolve  the  membrane.  The  patient  should  be  kept  in 
bed  during  the  attack  and  the  atmosphere  be  moistened  by  a  steam 
kettle.  Oxygen  should  be  at  hand  in  case  the  respiratory  difficulty 
becomes  urgent.  Iodide  of  potassium  and  mercury  have  been  recom- 
mended by  some  and  emetics  might  possibly  be  useful  in  some  cases. 


PULMONARY  COLLAPSE. 

Etiology. — Collapse  of  areas  of  the  lung  substance  is  of  common  occur- 
rence in  infancy,  and  adds  a  grave  danger  to  all  cases  of  bronchial 
catarrh.  Its  production  depends  largely  upon  the  yielding  nature  of 
the  ribs  and  cartilages  in  infancy,  especially  when  rickets  is  present, 
as  a  consequence  of  which  the  muscular  power  necessary  for  inspira- 
tion is  weakened,  the  inspiratory  suction  of  the  chest  walls,  whereby 
the  lung  is  inflated,  is  feeble,  and,  in  addition,  the  expiratory  air- 
blast,  by  means  of  which  the  bronchial  tubes  are  kept  clear,  possesses 
but  little  adequate  expulsive  power.  The  condition  may  arise  with 
stenosis  of  the  larynx,  trachea,  or  bronchi,  and  not  uncommonly  occurs 
in  quite  mild  cases  of  bronchitis,  the  secretion  in  the  larger  tubes  being 
suddenly  inhaled  and  causing  blocking  of  a  smaller  branch,  with  subse- 
quent collapse  from  absorption  of  the  imprisoned  air.  Some  amount 
of  superficial  collapse  accompanies  nearly  all  cases  of  bronchitis  in 
infants,  so  that  small,  dark,  depressed  areas  are  found,  postmortem, 
scattered  through  the  lungs  and  alternating  with  areas  of  compensatory 
emphysema.  Such  areas  give  rise  to  neither  physical  signs  nor  notice- 
able symptoms.  If  more  marked  they  cause  some  flattening  of  the 
percussion  note  down  the  back  of  the  chest,  especially  at  the  bases,  and 
their  extent  may  be  sufficiently  definite  to  be  mapped  out  by  percussion, 
but  if  shallow  they  will  give  rise  to  no  diminution  of  the  breath  sounds. 
Areas  of  collapse  sufficiently  large  to  cause  symptoms  commonly  occur 
at  the  base  and  down  the  posterior  border  of  the  lung  close  to  the  spine, 
generally  forming  a  wedge-shaped  area  with  the  base  below.  The  middle 
lobe  is  a  not  infrequent  seat  of  collapse,  especially  in  the  bronchitis  of 
older  children. 

Symptomatology.— When  considerable  collapse  occurs,  the  symptoms 
are  of  sudden  onset  and  often  develop  during  sleep.  The  infant  has 
generally  been  noticed  to  cough  and  wheeze  for  a  few  hours  or  a  day 
or  two;  perhaps  he  is  already  under  treatment  with  a  definite  bronchitic 
attack.     During  the  night  he  suddenly  wakes  screaming  and  fighting 


612  DISEASES  OF   THE  RESPIRATORY   TRACT 

for  breath,  tho  hreathint^  is  rapid  and  shallow,  and  the  child  becomes 
cyanosed,  cold  and  collapsed,  and  very  restless.  A'oniitin<jj  is  not  un- 
common at  the  onset,  and  convulsions  may  occur.  Death  follows  quite 
suddenly  in  some  cases. 

On  examination  marked  insj)iratory  recession  is  noticed  at  the  base 
of  the  chest  aloni,^  the  diaphraffinatic  attachment,  and  may  be  more 
marked  on  one  side  than  the  other.  IlyperinHation  (acute  emphysema) 
of  the  upper  parts  of  the  lun^s  occurs,  ])artly  as  a  compensatory  effect 
and  partly  as  a  result  of  the  violent  inspiratory  efforts,  and,  as  a  conse- 
fjuence,  the  uj)j)er  part  of  the  chest  appears  rounded  and  prominent. 
This  suj)era(lde(l  emphysema  becomes  as  nuich  an  element  in  the 
threatenin<]j  asphyxia  as  is  the  initial  collapse.  Over  the  bases  of  the 
chest,  on  one  or  both  sides,  where  the  aliected  area  li(>s,  the  breath 
sounds  are  feeble  or  absent,  and  the  expansion  is  diminisluxl,  but  there 
is  no  dulness  at  first.  It  is  only  after  the  imprisoned  air  has  been  al)sorbed 
that  the  area  becomes  impaired  or  dull  to  ])ercussi()n.  Over  the 
remainder  of  the  chest  bronchitic  rales  of  various  kinds  will  generally 
be  audible. 

Diagnosis. — When  the  collapse  is  considerable  in  extent  the  signs  of 
pleural  effusion  may  be  sinuilated — dulness,  absent  breath  sounds,  and 
diminished  vocal  resonance.  The  history  of  onset  in  such  cases,  the 
less  resistant  dulness,  and  the  signs  of  bronchitis  over  the  rest  of  the 
chest  will  usually  serve  as  distinctions.  When  the  collapsed  area  is 
large  in  extent  the  neighboring  viscera  will  move  over  toward  it,  and 
this  forms  a  most  valuable  distinction  from  pleural  effusion.  INIoreover, 
collapse  is  a  tlisease  of  infancy,  when  effusions  are  generally  purulent, 
and  give  signs  like  pneumonia  rather  than  those  likely  to  be  confoundetl 
with  collapse.  It  is  but  rarely  that  colla])se  is  sufficiently  massive  to 
give  the  ordinary  signs  of  consolidated  lung  (bronchial  breathing  and 
l)ronchophony).  When  such  occurs  it  is  generally  at  the  apex,  and  the 
area  is  found  at  the  autopsy  to  be  engorged  and  edematous,  and  to 
present  to  the  microscope  the  elements  of  a  commencing  pneumonia. 
Signs  somewhat  sinuilating  inflanunatory  consolidation  are  occasionally 
found  in  bronchitis  at  the  bcise  also,  and  their  luiture  can  usually  be 
determined  by  the  slighter  character  of  the  constitutional  symptoms 
and  the  rapidity  with  which  the  lesion  clears. 

Treatment. — This  must  be  directed  toward  the  removal  of  the  obstruc- 
tion in  the  tube,  or,  failing  this,  in  stimulating  inspiratory  effort  even 
at  the  expense  of  increasing  the  accompanying  emphysema.  Thus,  an 
emetic  may  be  given  if  the  secretion  in  the  tubes  is  abundant  and  loose. 
Ipecacuanha  powder,  0.7  gm.  (10  gr.),  or  wine  of  ipecac,  4  c.e.  (1  dr.), 
every  cjuarter  of  an  hour,  may  be  tried  and  the  fauces  tickled,  or  if 
these  measures  are  unsuccessful  the  passage  of  a  stomach  tube  will 
generally  bring  about  the  desired  result.  A  hot  mustard  bath,  15  gm. 
to  4  litres  ('  ounce  to  1  gallon),  should  be  given,  and  the  chest  sponged 
with  cold  water  to  induce  deep  inspiration;  the  skin  should  be  slapped 
until  vigorous  crying  is  induced,  and  liniments  or  dry-cupping  applied 
over  the  bases  of  the  lungs.     Belladonna  in    large   doses,  O.OIG  gm. 


EMPHYSEMA  5^3 

(i  gr.)  of  the  extract,  may  be  tried,  both  as  a  respiratory  stimulant 
and  for  the  purpose  of  drying  up  the  bronchial  secretion.  The  child 
must  be  roused  at  intervals  and  made  to  cry;  it  must  be  carried  about 
the  room  and  not  allowed  to  sleep  itself  to  death,  as  it  will  if  permitted. 
Oxygen  will  be  serviceable  if  given  at  intervals  and,  in  some  cases, 
artificial  respiration  may  be  needed. 


EMPHYSEMA. 

This  disease  is  dependent  upon  an  overdistention  of  the  lung  alveoli. 
In  some  cases  the  lesion  is  permanent  and  associated  with  atrophy  of 
alveolar  walls,  but  in  children  the  condition  is  often  temporary,  and, 
even  where  it  has  existed  for  many  years,  may  disappear  at  puberty. 
For  this  reason  the  term  Emphysema  may  be  used  to  cover  all  cases, 
or  may  be  reserved  for  permanent  cases  only,  the  latter  cases  being 
referred  to  merely  as  "hyperinflation."  For  clinical  purposes,  it  is  best 
to  include  all  conditions  of  alveolar  distention  under  the  heading  of 
Emphysema. 

Etiology. — Chronic  emphysema  in  children  is  always  the  result  of 
bronchial  catarrh.  Acute  emphysema,  or  hyperinflation,  occurs  in  any 
condition  of  which  dyspnea  is  a  marked  feature.  It  is  especially  common 
in  acute  bronchitis  and  bronchopneumonia,  but  also  occurs  with  laryn- 
geal obstruction,  whooping-cough,  asthma,  and  other  respiratory  con- 
ditions. It  is  a  constant  and  serious  accompaniment  of  pulmonary 
collapse,  in  which  case  it  is,  no  doubt,  in  part  compensatory. 

No  disease  has  given  rise  to  more  discussion  with  regard  to  its  mode 
of  origin  than  has  emphysema.  Two  hypotheses  are  commonly  advanced 
to  explain  its  occurrence,  the  inspiratory  and  expiratory,  to  which  is 
added  "hereditary  predisposition"  by  many.  As  a  matter  of  fact  two 
very  different  varieties  of  emphysema  are  observable,  and  there  is  good 
reason  to  believe  that  they  are  of  different  causation.  One  is  the  marked 
condition,  often  associated  with  the  formation  of  air-containing  bullse, 
occurring  in  the  unsupported  portions  of  the  lung,  the  anterior  margins 
of  the  upper  lobes,  the  edges  at  the  bases,  and  often  the  extreme  apex, 
and  this  is  produced  by  the  forces  of  expiration,  as  in  violent  and  pro- 
longed coughing.  Interstitial  emphysema  is  also  of  this  type.  The 
other  variety  is  the  general  emphysema  which  leads  to  enlargement  of 
the  organ  as  a  whole.  This  is  probably  due  to  violent  inspiratory 
efforts  the  result  of  dyspnea,  especially  in  such  diseases  as  asthma 
and  bronchitis,  where  expiration  also  is  hindered  by  obstruction  in  the 
tubes.  The  condition  itself  depends  on  a  loss  of  elasticity  of  the  lung, 
whereby  it  tends  to  remain  in  the  position  of  inspiration  instead  of 
returning  to  the  normal  position  of  rest.  This  loss  of  elasticity  is 
due  to  overstretching,  aided  in  many  cases  by  inflammatory  changes. 
There  is  reason  to  believe,  also,  that  a  congenital  weakness  of  the 
elastic  tissue  of  the  lung  leads  to  a  more  ready  production  of  the  disease. 

Compensatory  emphysema  occurs  whenever  the  volume  of  the  lung  is 
reduced,  as  by  an  area  of  fibrosis  or  collapse.    Its  production  is  purely 


(314  DISEASES  OF   THE  RESPIRATORY   TRACT 

mechanical,  and  it  probably  compensates  in  no  way  for  the  loss  of 
aeratini;  s\u"fa('o  cansed  by  the  condition  which  l)rin<^s  it  abont. 

Pathology. — The  morbid  anatomy  of  this  condition  is  similar  to  the 
condition  fonnd  in  the  adnlt.  The  emphysematons  lung  is  more  vol- 
uminous than  the  normal.  It  is  pale  pink  in  color,  soft  to  the  touch, 
and  the  individual  alveoli  are  plainly  visible  to  the  naked  eye.  In  cases 
of  lonj^er  standinu;  there  are,  in  addition  to  the  simply  over-distended 
air  sacs,  some  lart^er  blebs  made  by  the  fusion  of  a  terminal  air  ])assage 
(infundibuhnn)  with  its  surrounding  alveoli,  or  of  a  number  of  air  vesi- 
cles through  rupture  of  their  walls.  (Wollstein.) 

Histology. — In  the  mild,  acute  form,  which  is  really  only  an  overdis- 
tention,  microscopic  examination  shows  merely  a  dilatation  of  the  air 
vesicles,  find  a  conscfjuent  thinning  of  their  walls  with  stretching  or 
straightening  of  the  capillary  network.  The  walls  between  neighboring 
alveoli  may  be  torn  or  entirely  disappear. 

In  older  more  chronic  cases  atrophy  of  the  elastic  tissue  and  ca])il- 
laries  in  the  alveolar  walls  occurs,  and  neighboring  alveoli,  having  lost 
their  dividing  walls  through  thinning  and  perforation,  join  to  make 
large  blebs.    Such  cases  are  rare  in  childhood. 

Symptoms. — Acute  emphysema  most  commonly  occurs  in  acute 
bronchitis  and  bronchopneumonia;  it  is  also  present  with  pulmonary 
collapse  and  adds  largely  to  the  respiratory  disability.  The  upper  parts 
of  the  chest  are  very  prominent,  as  in  the  position  of  inspiration,  and  there 
may  be  some  recession  at  the  base,  along  the  diaphragmatic  attachment. 
The  percussion  note  is  deep  and  full,  the  cardiac  dulness  covered,  and 
the  respiratory  murnnn-  harsh.  The  condition  recovers  completely  when 
the  cause  is  removed,  though  the  lung  may  take  some  time  to  return 
to  normal  after  a  prolonged  strain  such  as  whooping-cough  entails. 

Chronic  emphysema  is  rare  in  childhood;  conmionly  the  condition  is 
slight,  and  the  symptoms  largely  or  entirely  those  of  the  accompanying 
bronchitis.  The  elements  added  V)y  the  disease  itself  are  dyspnea, 
caused  by  the  loss  of  respiratory  surface,  and  cardiac  disability,  due  to 
the  straightened  circulatory  paths  through  the  lung. 

Dyspnea  is  sometimes  considerable,  persisting  even  through  the 
summer  months,  when  no  bronchitis  is  present.  In  many  cases  it  is 
only  noticeable  on  exertion,  except  during  the  attacks  of  bronchitis, 
which  so  commonly  occur,  often  in  association  with  some  bronchial 
spasm.  The  face  is  then  congested  and  cyanosed,  and  the  veins  in  the 
neck  may  be  full  or  even  pulsating.  Some  amount  of  finger-clubbing 
exists  as  a  permanent  feature  in  certain  cases  of  long  standing. 

Physical  Signs. — In  a  marked  example,  the  chest  is  in  the  position 
of  full  inspiration  and  appears  unduly  rounded,  the  back  being  some- 
times bowed.  The  angle  of  Ludwig  is  prominent,  the  clavicles  project, 
the  supraclavicular  fossae  being  deep,  or  filled  l)y  the  bulging  apices  of 
the  lungs;  the  sternomastoids  stand  out,  and  the  costal  angle  appears 
wide.  The  heart's  apex  beat  may  be  difhcult  to  pal])ate,  and  an  epigastric 
pulsation  is  generally  visible.  'I'he  movements  of  the  chest  are  confined, 
and  consist  mainly  in  an  up-and-down,  piston-like  action. 


BROXCHIAL  ASTHMA  6I5 

The  lung  gives  a  box7,  hyperresonant  note  to  'percussion,  the  heart's 
duhiess  IS  covered  or  partly  covered,  and  in  many  cases  the  pulmonary 
limits  are  found  to  encroach  on  the  abdominal  organs  below. 

On  auscultation  the  breath  sounds  are  harsh,  especially  over  the 
upper  parts  of  the  chest  in  front;  there  may  be  a  pause  at  the  end  of 
inspiration,  and  expiration  is  unduly  prolonged.  The  sio-ns  of  bron- 
chitis are  generally  present,  and  the  air  entry  is  often  very  deficient  at 
the  bases. 

Prognosis.— This  is  more  hopeful  in  children  than  in  adults.  Marked 
cases  progress  into  adult  life,  but  it  sometimes  haj)pens  that,  in  cases 
associated  with  chronic  bronchitis,  when  puberty  is  reached  the  con- 
dition becomes  less,  or  may  disappear,  showing  that  but  little  structural 
defect  could  have  existed  in  the  lungs.  The  prognosis,  both  as  regards 
permanent  cure  and  the  prolongation  of  fife  in  incurable  cases,  depends 
largely  upon  the  social  standing  of  the  patient. 

Treatment.' — The  treatment  is  mainly  that  of  the  disease  it  accom- 
panies, and  must  be  sought  under  other  headings.  Emphysema  when 
associated  with  chronic  bronchitis  adds  considerably  both  to  the  liabilitv 
to  and  to  the  danger  of  acute  attacks,  and  these  must  be  avoided,  if 
possible,  by  change  to  a  mild  climate  during  the  winter  months.  In 
addition  something  may  be  tried  by  way  of  treatment  for  the  emphysema 
itself.  That  which  has  been  attended  by  the  greatest  success  has  been 
the  daily  use  of  the  compressed-air  bath  with  the  pneumatic  cabinet; 
in  it  the  size  of  the  chest  becomes  reduced,  and  the  cardiac  and  hepatic 
dulness  return  toward  their  normal  limits.  Another  method  is  that 
of  expiration  into  rarefied  air,  a  proceeding  the  rationale  of  which  is 
more  obvious,  but  the  results  less  brilliant. 

BRONCHIAL  ASTHMA. 

A  proportion  of  cases  of  asthma  begin  during  the  early  years  of  life, 
and  this  proportion  is  variously  estimated  by  difi^erent  observers.  Thus 
Hyde  Salter  among  225  cases  found  11  beginning  in  the  first  year  of 
life  and  60  between  the  ages  of  one  and  ten  years.  Goodhart  among 
123  cases  finds  51  beginning  before  the  tenth  year,  the  youngest  of 
these  being  three  and  a  half  years  of  age.  Lately  Dr.  La  Fetra  has 
collected  43  cases  in  children  and  their  analysis  shows  the  following  age 
of  onset: 

Beginning  at  birth 3  cases. 

"  "  first  year 11     " 

"  "  second  year 8     " 

"  "  second  to  fifth  year 9     " 

"  "  fifth  to  twelfth  year 15     " 

He  finds  that  after  the  first  year  is  past  the  incidence  is  much  greater 
in  males  than  in  females. 

With  all  due  deference  to  these  figures  it  must  be  stated  emphatically 
that  cases  of  uncomplicated  asthma  in  children  are  distinctly  rare. 
There  is,  however,  a  variety  of  asthma  which  is  not  infrequently  met, 


616  DISEASES  OF   THE  RESPIRATORY   TRACT 

and  this  is  an  association  of  bronchial  sj^asni  witli  attacks  of  bronchitis 
in  diildhood,  this  spasm  bcin<i;  HabU'  to  recur  witli  each  siibsc(iuent 
bronchial  catarrh.  Such  cases  arc  familiar  to  most  of  us,  the  dyspnea 
generally  lasting  a  day  or  two,  and  giving  rise  to  considerable  hyj)er- 
infiation*  of  the  lungs.  It  is  probably  cases  of  this  nature  which  for  the 
most  part  swell  the  statistics  of  asthma  in  children,  and,  in  accordance 
with  this,  one  finds  that  all  observers  mention  bronchial  catarrh  as  an 
important  causative  factor.  'J'hus  SO  per  cent,  of  Salter's  cases  origi- 
nated with  whooping-cough;  20  of  Goodhart's  cases  had  suffered  with 
bronchitis,  anrl  many  with  measles  and  whooping-cough;  7  had  had 
l)ronchopneumonia.  Among  La  Fetra's  cases  14  were  assigned  to 
bronchitis  and  'A  to  varieties  of  pneumonia. 

Pathology. — The  theory  of  spasm,  so  clearly  proved  by  the  recent 
work  of  Dixon  and  Brodie,  is  especially  striking  in  view  of  the  pre- 
valence of  adenoid  growths  in  cases  of  asthma  in  children.  It  was 
founfl  experimentally  by  these  observers  that  the  greatest  reflex  effect 
was  obtained  when  the  nasal  mucous  membrane,  and  especially  the 
upper  and  posterior  part  of  the  nasal  septum,  was  stimulated.  La  Fetra 
found  adenoids  present  in  47  per  cent,  of  his  collected  cases. 

Symptoms. — Attacks  may  occur  similar  to  those  found  in  the  adult, 
and  in  this  case  their  symptoms  merit  no  separate  description.  In 
cases  of  spasm  associated  with  bronchitis  it  is  not  always  easy  to  decide 
how  far  either  of  these  elements  is  responsible  for  the  distress  which  is 
present.  The  most  noticeable  feature  is  the  marked  dyspnoea,  gen- 
erally accompanied  by  cyanosis,  and  the  heaving  respiratory  move- 
ments of  the  barrel-shaped  chest.  The  picture  of  the  elderly  bronchitic 
with  emphysema  is  strikingly  reproduced. 

On  examining  the  chest  emphysema,  or,  more  correctly,  "hyper- 
inflation," is  very  noticeable,  the  extraordinary  muscles  of  respiration 
are  in  action,  and  the  thorax  moves  up  and  down  witli  a  piston-like 
action.  The  lungs  are  full  of  wheezy  sibili  and  rhonchi,  which  are 
peculiar  in  that  they  are  audible  alike  with  expiration  as  with  inspira- 
tion. The  duration  of  these  attacks  is  measured  not  by  hours,  as  in 
classical  asthma,  but  by  days. 

Treatment. — The  most  important  point  in  treatment  is  to  remove 
the  predisposition  to  those  bronchitic  attacks  which  so  often  initiate 
the  bronchial  spasm.  For  this  the  reader  is  referred  back  to  the  section 
on  Bronchitis,  where  this  matter  is  discussed.  Change  of  climate  may 
be  necessary  in  some  cases,  and  should  certainly  be  urged  where  other 
means  fail.  At  the  same  time  any  local  disease,  such  as  adenoids,  must 
be  scruj)ulously  attended  to. 

For  the  attacks  the  nitrate  and  stramonium  papers  may  be  used  as 
in  adults,  and  where  bronchitis  is  associated  a  steam  kettle  and  wine  of 
ipecac  or  wine  of  antimony  are  of  great  value.  For  the  spasm  m'tro- 
glycerin,  0.0000  to  0.0012  gm.  fyoir  t<)-Vf?'''ii'Oi  every  half  hour  for  two 
or  three  doses,  or  atropine  or  belladoima,  0.01 7  gm.  (|^  grain),  extract, 
repeated  till  flushing  of  the  face  ensues,  have  often  been  successfully 
employed. 


CHAPTEE  XXV. 

BRONCHOPNEUMONIA— LOBAR  PNEIBIONIA. 
BRONCHOPNEUMONIA. 

Etiology. — The  term  Bronchopneumonia  signifies  a  lung  inflammation 
of  certain  well-recognized  type,  and  as  such  embraces  conditions  of 
various  causation.  For  purposes  of  classification,  cases  are  conveniently 
divided  under  two  headings,  primary  and  secondary  bronchopneumonia, 
the  latter  being  again  subdivided  into  many  groups. 

Secondary  bronchopneumonia,  as  the  name  implies,  comprises  all  such 
cases  as  are  secondary  to  other  diseases,  the  majority  being  either  the 
outcome  of  an  acute  bronchitis  of  simple  causation,  or  arising  in  the 
bronchial  catarrh  which  so  commonly  accompanies  certain  of  the 
specific  fevers,  more  especially  measles,  whooping-cough  and  influenza; 
the  remainder  consisting  of  cases  of  septic  origin,  and  those  which 
terminate  such  diseases  as  marasmus,  splenic  anemia,  and  chronic 
diarrhea.  Lobular  pneumonia  is,  in  most  cases,  a  purely  local  disease 
of  the  lungs  and  lobular  in  distribution. 

Primary  hronclwpneumonia  comprises  all  such  cases  as  arise  without 
antecedent  illness.  It  is  generally  caused  by  the  pneumococcus,  and  is 
distinguished  from  the  secondary  disease  by  its  abrupt  onset  and  its 
occurrence  in  healthy  children.  In  some  cases  the  general  symptoms 
are  marked  and  a  close  resemblance  to  croupous  pneumonia  obtains, 
but,  as  a  rule,  the  local  symptoms  overshadow  those  of  general  infection, 
and  it  is  to  the  former  that  the  anxious  course  and  high  mortality  in 
bronchopneumonia  are  nearly  always  due.  As  a  consec|uence  of  this, 
the  symptoms  of  all  varieties  of  the  disease,  whatever  the  cause,  are 
sufficiently  similar  to  be  grouped  together  for  purposes  of  description, 
being  dependent  so  largely  upon  the  local  processes  in  the  lungs. 

The  diagnosis  of  primary  bronchopneumonia  rests  upon  its  sudden 
onset  without  antecedent  illness,  and  it  is  open  to  conjecture  whether 
two  classes  of  cases  are  not  included  under  this  heading.  It  happens 
sometimes  that  an  illness  having  all  the  features  of  a  croupous  pneu- 
monia, with  its  sudden  onset,  high  continuous  fever,  and  short,  definite 
course  terminating  by  crisis  in  many  cases,  presents  to  examination  all 
the  physical  signs  of  bronchopneumonia,  or  shows  the  lesions  of  that 
disease  on  the  postmortem  table.  Such  cases  are  undoubtedly  general 
blood  infections,  and  as  such  stand  side  by  side  with  croupous  pneu- 
monia which  they  so  closely  resemble.  They  form  but  a  small  pro- 
portion, however,'  of  those  cases  to  which  the  term  primary  broncho- 
pneumonia is  applicable,  and  it  seems  probable  that  the  remainder  are 

(617) 


61S  DISEASES  OF   THE  RESPIRATORY    TRACT 

of  different  origin,  being  clue  probably  to  a  sudden  invasion  through  the 
small  bronc-hial  tubes,  a  capillary  bronchitis,  whether  scattered  in 
distr.bution  or  general.  To  put  it  ditl'ereutly,  in  one  class  the  lung  is 
invaded  from  the  blood  stream  and  in  the  other  from  the  air  tubes; 
the  distribution  of  blood  and  air  to  the  pulmonary  lobule  being  similar 
the  lesions  produced  are  identical.  This  is  well  illustrated  by  pulmonary 
tul)erculosis  in  which  the  lobular  distribution  of  acute  phthisis  mav  be 
exactly  irxitated,  in  isolated  areas,  by  the  blood  invasion  of  miliary 
tuberculosis. 

I  have  attempted  to  tabulate  a  series  of  cases  of  bronchopneumonia, 
236  in  all,  to  show,  at  any  rate  roughly,  the  proportions  in  which  the 
primary  and  secondary  cases  occur: 

Primary 80  cases  or  .34  per  cent.       Mortality  60  per  cent. 

Secondary 156  cases  or  66  per  cent. 

to  bronchitis 58  cases.  "  64 

"           "  whooping-coughi 28      "  "  50  " 

"          "  measles' 36     "  "  53  " 

•'  diphtheria 7      "  "  100  " 

"           "  diarrhea 13     "  "  100  " 

"           "  sepsis 11      "  "  100  " 

"          "  marasmus  and  congenital  syphilis     .        3     "  "  100  " 

156      " 

Incidence. — Broncliopneumonia  is  a  disease  of  infancy  and  is  not 
commonly  met  in  children  above  the  age  of  three  years,  the  majority 
of  the  cases  probably  occurring  between  the  sixth  and  twelfth  months 
of  life.  It  is  most  prevalent  during  the  winter  months,  corresponding 
in  this  respect,  as  might  be  expected,  with  bronchitis.  It  occurs  most 
widelv  among  the  children  of  the  poor  and  is  especially  prevalent  in 
overpopulated  areas. 

Pathology.  Bacieriology. — Most  of  the  workers  on  this  subject  have 
failed  to  separate  the  primary  and  secondary  cases.  The  only  complete 
account  on  these  lines  is  that  given  by  Dr.  L.  Emmett  Holt  in  his  book 
on  diseases  of  children  from  cases  collected  by  Dr.  Martha  WoUstein. 
From  this  it  appears  that  76  per  cent,  of  the  primary  cases  were 
caused  by  the  pneumococcus,  the  other  organisms  found  being  mainly 
streptococci  and  staphylococci.  Among  the  secondary  cases,  in  64  per 
cent,  the  pneumococcus  was  present,  but  the  majority  were  due  to  a 
mixed  infection,  a  streptococcus  being  found  in  37  per  cent.,  the  other 
organisms  present  being  of  various  kinds  and  including  such  varieties 
as  staphylococcus,  bacillus  diphtheritie,  bacillus  pyocyaneus,  and  bacillus 
coli  communis.  The  streptococci  were  associated  in  especial  frequency 
with  cases  secondary  to  the  infectious  fevers. 

Morbid  Anatomy. — The  consolidation  may  be  scattered,  or  may 
involve  large  areas,  even  the  whole  of  a  lobe,  in  which  case  the  affected 
part  will  appear  voluminous  and  the  pleural  surface  roughened,  show- 
ing petechial  hemorrhages  and  covered  with  a  thin  layer  of  fibrin. 
The  appearances  of  the  bronchopneumonic  parts  are  very  various,  the 
consolidated  areas  generally  appearing  as  light  points  off  a  background 

>  A  higher  age  average  was  probably  accountable  for  the  lower  mortality  among  these  cases. 


BRONCHOPNEUMONIA 


619 


of  dark-brown,  congested  lung.  They  are  the  size  of  pinheads  or  larger, 
and  are  arranged,  some  in  a  circle  round  a  small  pus-containing  bronchus' 
some  in  clumps  showing  no  relation  to  the  air  tubes,  some  themselves 
pierced  by  a  minute  bronchus  and  forming  a  peribronchial  nodule.  In 
massive  consolidation  the  whole  surface  appears  firm  and  smooth,  red 
marbled  with  various  shades  of  gray. 

With  regard  to  the  color  of  the  pneumonic  patches  this  varies  greatly 
according  to  the  form  of  microscopic  element  composing  it.  No  division 
into  stages  can  be  made  as  in  croupous  pneumonia.  The  areas  are 
usually  slightly  raised  and  reddish-gray  in  color;  where  there  is  much 
leukocytic  infiltration  they  appear  whiter.  In  acute  cases  the  areas  are 
small  and  gray  or  yellowish-white  in  color  and  the  tubes  contain  muco- 
pus ;  when  the  process  is  earlier  still,  bronchitis  with  minute  dark  points 
of  collapse  may  be  seen.  In  cases  of  long  continuance  the  areas  are 
usually  large,  and  greenish  or  yellowish  in  color,  and  the  small  tubes 
contain  pus.  In  many  such  chronic  cases  the  larger  bronchial  tubes 
are  dilated  at  the  root  and  in  the  lower  lobes,  and  occasionally  the  finer 
divisions  also.  Small  abscesses  may  be  found  scattered  through  the 
hmgs,  especially  just  beneath  the  pleural  surface.  They  are  generally 
formed  round  the  walls  of  a  small  bronchus  through  softening  of  a 
peribronchial  nodule;  in  some  cases  the  pus  in  a  localized  dilatation  of 
a  bronchiole  appears  like  a  minute  abscess. 

It  is  common  to  find  much  collapse  in  the  lower  lobes,  especially,  I 
think,  in  cases  of  diphtheritic  origin,  and  also  some  emphysema  of  the 
upper  and  anterior  parts  of  the  lungs.  The  septic  cases  tend,  in  my 
experience,  to  be  lobar  in  distribution,  an  upper  lobe  being  not  un- 
commonly attacked,  and  there  is  usually  considerable  engorgement  and 
edema  of  the  less  affected  portions  of  the  lungs. 

Histology. — Much  variety  is  found  in  the  microscopic  appearances. 
The  small  bronchi  contain  plugs  of  epithelial  cells,  or  of  polymorpho- 
nuclear leukocytes.  The  most  infiltrated  areas  generally  surround  these 
bronchi,  but  may  be  scattered  elsewhere.  These  areas  usually  consist 
of  dense  masses  of  leukocytes,  both  filling  the  alveoli  and  also  infil- 
trating the  bronchial  and  alveolar  walls.  The  interalveolar  capillaries 
are  engorged  and  patches  of  collapsed  air  cells  are  seen  here  and  there. 
Other  areas  are  found  in  which  the  alveoli  are  filled  with  blood  cells 
and  with  granular  fibrin  and  serum;  their  epithelium  is  swollen  in 
places,  and  in  parts  of  the  section  the  alveoli  may  be  seen  filled  with 
desquamated  lining  cells.  In  cases  where  the  process  has  been  of  long 
duration  the  alveolar  walls  are  thickened  with  proliferated  connective- 
tissue  cells,  an  earnest  of  that  process  which  in  some  cases  leads  on  to 
a  widespread  fibrosis. 

Symptomatology.  Onset. — As  the  symptoms  of  onset  of  the  primary 
and  secondary  varieties  of  the  disease  are  somewhat  different  it  will  be 
necessary  to  describe  these  separately. 

Primary  Bronchopneumonia. — Cases  occur,  as  already  indicated, 
which  are  indistinguishable  from  croupous  pneumonia  save  for  the 
difference  of  the  lesion  found  in  the  lungs.     The  symptoms  of  these 


620  DISEASES  OF  THE  RESPIRATORY   TRACT 

cases  need  no  further  description  here;  it  suffices  to  remember  that  all 
the  synij)toms  of  crouj)ous  pneumonia  may  occur  with  a  broncho- 
pneumonic  lesion. 

In  the  remainder  the  onset  is  jj^enerally  abrupt;  it  may  be  less  sudden 
and  more  accurately  described  lus  "rapid."  The  respiratory  difficuUi/, 
fever,  and  cough  are  generally  the  first  things  noticed,  though  some  more 
definite  sym])tom  such  as  vomiting  may  occur  at  the  start.  Convulsions 
are  but  rarely  seen  and  a  rigor  almost  never.  The  skin  may  be  dry  and 
bm-ning,  us  in  croupous  pneumonia,  but  often  there  is  sweating.  The 
bowels  may  be  costive  at  the  connnencement,  but  diarrhea  nearly  always 
follows,  and  may  obtain  from  the  beginning.  As  in  croupous  pneu- 
monia robust  children  are  attacked,  which  less  often  happens  in  second- 
ary cases. 

Secondary  Bronchopneumonia. — In  those  cases  which  follow  on 
bronchitis  of  the  larger  tubes,  there  occur  first  the  ordinary  symptoms 
of  this  disease,  cough  and  fever,  sometimes  accompanied  or  preceded 
by  nasal  and  pharyngeal  catarrh,  and  these  symptoms  either  gradually 
increase,  or,  more  often,  after  they  have  lasted  a  variable  time,  the 
child  suddenly  becomes  worse,  the  cough  gets  dry,  hacking  and  distress- 
ing, the  respiration  rapid  and  difficult,  and  in  a  short  time  all  the  symp- 
toms of  bronchopneumonia  become  evident. 

In  cases  following  the  specific  fevers  the  l)ronchopneumonia  may 
either  begin  during  their  course  or  more  often  tliere  is  an  interval  of 
a  week  or  two  during  which  the  bronchitis  continues,  and  then  gradually 
increases  in  severity  to  pass  into  the  more  serious  disease.  Secondary 
bronchopneumonia  from  the  conditions  under  which  it  occurs  is  usually 
found  in  sickly  and  ill-nourished  infants. 

General  Symptoms. — After  the  onset  is  past  and  the  disease  fully 
established,  the  symptoms  are  closely  similar  in  the  primary  and  sec- 
ondary cases;  where  differences  occur  these  will  l)e  pointed  out. 

The  child  shows  a  flushed  face  in  the  early  stages;  later  it  may  appear 
pale.  The  skin  is  hot  and  moist,  sometimes  dry  and  ])urning  in  the 
primary  cases;  the  respirations  are  ra])id  and  the  alte  nasi  work.  In 
many  cases  there  is  slight  cyanosis  of  the  lips  and  ears,  and  when  distress 
is  more  urgent  there  may  be  a  leaden  tint  over  the  whole  face.  The 
child  is  restless  and  irritable  and  refuses  food,  but  is  thirsty;  in  infants 
the  breast  is  often  refused  owing  to  the  urgent  needs  of  the  respiratory 
.system.  Diarrhea  generally  occurs,  and  occasionally  vomiting  when 
the  cough  is  troublesome.  Nasal  discharge  is  often  observed  and  also 
conjunctivitis  in  some  cases.  Stomatitis  and  pharyngitis  are  not  un- 
common. 

The  cough  in  bronchopneumonia  is  generally  a  more  important  feature 
than  in  croupous  pneumonia;  it  is  dry  and  hacking  and  often  very 
frequent  and  distressing.  There  is  no  expectoration  in  children,  but 
sometimes  some  viscid  nnicus  is  brought  into  the  mouth.  Vomiting 
not  infrecjuently  accompanies  the  cough,  both  at  the  commencement 
and  also  later  when  the  cough  is  looser  or  sometimes  spasmodic,  as  it 
may  be  even  in  cases  which  do  not  accompany  whooping-cough.     The 


BRONCHOPNEUMONIA 


621 


sleep  is  often  disturbed  by  cough,  and  the  attacks  cause  a  temporary 
bkieness  round  the  hps  and  eyes.  In  cases  following  whooping-cough 
the  characteristic  cough  may  disappear  during  the  attack  and  only 
return  with  convalescence. 

The  dyspnea  is  often  extreme  and  depends  chiefly  upon  the  amount 
of  the  accompanying  bronchitis  of  the  small  tubes.  The  respirations 
are  rapid,  and  the  pulse-respiration  ratio  disturbed.  In  some  cases  this 
ratio  is  reduced  to  2  :  1,  more  often  only  3  :  1,  but  in  slight  cases  it  may 
be  but  little  altered  from  the  normal,  and  does  not  form  a  valuable 
point  of  distinction  from  cases  of  bronchitis.  The  breathing  is  often 
accompanied  by  a  short  grunt  or  gasp  at  the  beginning  of  expiration, 
though  this  is  usually  a  less  noticeable  feature  than  in  croupous  pneu- 
monia. Where  there  is  much  respiratory  difficulty  the  ala  nasi  work, 
and,  if  any  cyanosis  is  present,  they  will  be  seen  to  dilate  vigorously. 
In  slight  or  chronic  cases  where  breathing  is  not  much  disturbed  they 


Fig. 132 


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Temperature  chart,  case  of  bronchopneumonia. 

may  be  quite  inactive.  When  the  amount  of  air  reaching  the  lung 
alveoli  is  much  reduced  there  is  distressing  dyspnea.  The  child  is  deeply 
cyanosed,  with  a  cold,  damp  skin,  and  the  whole  attention  is  given  to 
the  respirator}^  functions;  if  the  condition  is  not  relieved  the  lung  becomes 
more  and  more  choked,  tracheal  rales  appear,  drowsiness  supervenes, 
and  as  the  cvanosis  increases  unconsciousness  and  death  soon  follow.  ^ 
The  temperature  shows  wide  variations  in  bronchopneumonia  and  is 
perhaps  more  inclined  to  be  high  in  primary  than  in  secondary  cases. 
But  seldom  is  the  temperature  so  high  as  in  croupous  pneumonia,  101° 
to  103°  F.  being  a  common  evening  standard,  with  a  drop  of  3°  or  4° 
by  morning  (Fig.  132).  This  swinging  temperature  goes  on  through- 
out the  attlick,  and  is  as  much  a  feature  of  the  primary  as  of  the  sec- 
ondary cases.  In  slight  cases  the  temperature  sometimes  only  rises  to 
99°  or  100°  F.  and  falls  to  97°  or  98°  F.  in  the  morning;  sometimes 


622  DISEASES  OF   THE  RESPIRATORY   TRACT 

fluctuations  of  only  2°  are  observed.  In  rare  cases  the  temperature 
remains  normal  throuo;hout;  these  are  cases  with  marked  wastiiifii;  and 
are  not  of  favorable  outlook.  Hyperpyrexia  but  rarely  occurs  in 
bronchopneumonia  unless  as  a  terminal  event. 

Generally  tlie  disease  subsides  with  a  gradual  lowering  of  the  temper- 
ature extending  over  many  days  or  weeks,  but  occasionally  a  crisis  occurs 
as  in  croupous  pneumonia,  and  that  in  secotidary  as  well  as  in  primary 
cases.  As  a  rule,  the  temperature  nuikes  a  few  swings  after  the  critical 
fall,  and  very  rarely  presents  the  continuous  subnormal  temperature 
so  commonly  found  for  a  few  days  after  the  crisis  in  croupous  pneu- 
monia. Moreover,  the  respirations  do  not  drop  to  normal  so  rapidly 
thereafter  in  bronchopneumonia. 

In  the  primary  cases  the  skin  may  be  hot  and  dry  as  in  croupous 
pneumonia,  and  remain  so  throughout.  In  most  cases  there  is  sweating, 
and  this  is  always  a  feature  of  the  secondary  cases.  It  is  often  profuse 
when  the  temperature  falls  in  the  early  morning,  anfl  generally  most 
noticeable  over  the  head  and  face.  In  the  rickety  children  so  often  the 
subjects  of  bronchopneumonia  it  is  very  marked,  but  marked  sweating 
occurs  apart  from  rickets.  In  some  cases  of  bronchopneumonia  with 
considerable  wasting,  patches  of  fine,  close-set  petechial  spots  may 
appear  over  the  abdomen,  forming  pur])lish  patches  which  are  of  very 
fatal  omen. 

Diarrhea  \sni\  almost  constant  accompaniment  of  bronchopneumonia, 
whether  primary  or  secondary,  and  is  often  severe.  It  sometimes 
precedes  it  and  is  probably  then  a  ])redisposing  cause  of  the  initial 
bronchitis.  Four  or  five  loose  motions  daily  are  commonly  passed, 
and  these  often  contain  undigested  food  and  are  very  offensive.  The 
diarrhea  often  adds  considerably  to  the  gravity  of  the  case.  Vomiting 
is  an  occasional  initial  symptom;  more  commonly  it  occurs  as  a  result 
of  coughing  and  thereby  assists  in  the  expectoration  of  phlegm. 

Nervous  symptoms  are  much  less  commonly  seen  than  in  croupous 
pneumonia  and  are  of  more  serious  import.  Convulsions  occasionally 
occur,  or  twitchings  of  the  facial  muscles  and  passing  strabismus,  gener- 
ally at  the  onset  in  primary  cases  where  the  general  poisoning  has  been 
marked.  Now  and  then  a  case  is  met  where  the  symptoms  from  the 
beginning  suggested  a  vertical  meningitis,  and  where  at  the  autopsy 
nothing  but  bronchopneumonia  appears,  as  in  a  child  who  was  con- 
vulsed for  sixty  hours  up  to  death  and  in  whom  bronchopneumonia  was 
the  sole  lesion  disco vercfl. 

Physical  Signs. — These  vary  greatly  in  different  cases.  They  are  at 
first  those  of  l)ronchitis  only  and  may  remain  so  throughout  the  attack, 
but  generally  some  definite  signs  of  consolidation  appear.  The  signs 
are  nearly  always  most  marked  in  the  lower  lobes  behind,  and  very 
rarely  does  consolidation  occur  at  an  apex  except  where  other  parts 
of  the  same  or  opposite  lung  are  also  involved. 

On  inspection  it  is  generally  noticeable  that  the  upper  parts  of  the 
chest  are  prominent  and  the  thorax  held  in  the  position  of  inspiration; 
this  is  due  to  a  hyperinflation  of  the  lungs,  a  temporary  emphysema, 


BRONCHOPNEUMONIA 


623 


caused  by  the  inspiratory  dyspnea.  It  is  accompanied  in  many  cases 
by  some  inspiratory  recession  at  the  base  of  the  chest,  and  this  may  be 
very  marked  when  the  obstruction  in  the  small  tubes  is  great.  Rickets 
is  very  commonly  present  in  cases  of  bronchopneumonia,  and  a  deformed 
chest  with  submammary  groove,  wide  epigastric  angle,  and  a  thrusting 
forward  of  the  lower  rib  cartilages  is  often  to  be  observed. 

Palpation  and  Percussion. — Where  the  acute  emphysema  is  marked 
the  heart  is  largely  covered  and  the  apex  beat  may  be  difficult  to  find, 
but  it  can  generally  be  palpated  either  in  the  normal  or  just  outside 
the  normal  situation.  The  percussion  note  over  the  front  of  the  chest 
may  appear  somewhat  boxy  and  hyperresonant ;  behind  it  is  often  poor 


Fig. 133 


Child  with  bronchopneumonia. 

over  both  sides  from  the  presence  of  small  areas  of  collapse,  especially 
at  the  bases.  Such  signs  are  those  commonly  present  in  bronchitis,  but, 
in  addition,  there  generally  appears  more  definite  dulness  at  the  bases 
behind,  due  to  the  presence  of  areas  of  lung  consolidation.  The  dulness 
may  be  slight  with  a  high-pitched  note;  occasionally  it  is  marked  with 
increased  resistance  to  percussion,  and  involves  the  greater  part  of  a 
lobe  so  as  to  simulate  the  consolidation  of  croupous  pneumonia  (Figs. 
133  and  134). 

Auscultation.— Over  the  front  of  the  chest  the  breath  sounds  may 
appear  somewhat  harsh  on  account  of  the  emphysema;  commonly  they 
are  not  appreciably  altered  from  the  normal. 

Rales  of  various  sorts  and  sizes  may  be  audible  scattered  over  the 


624 


DISEASES  OF   THE  RESPIRATORY   TRACT 


lungs,  often  moist  in  tlie  .small  and  dry  in  the  large  tubes.  Often  the 
rales  are  confined  to  the  bases  behind.  These  are  the  signs  of  bronchitis 
and  in  the  early  stages  nothing  more  definite  may  l)e  found,  but  later 
signs  pointing  to  consolidation  also  appear.  First,  there  may  be  heard 
at  the  bases  behind  fine  or  medium-sized  rales  with  the  peculiar  sharp, 
resonant,  metallic  quality  which  tlenotes  the  presence  of  lung  consoli- 
dation around  the  tubes.  Secondly,  there  may  be  signs  pointing  to 
definhe  areas  of  consolidation,  mostly  at  the  bases  behind.  In  such 
case  bronchial  or  tubular  breathing  will  be  heard,  generally  intense  and 


Fig. 134 


Brouchopneumonia.     Girl  of  .sixteen  months ;  dots  represent  crepitations  and  the  lines 
represent  percussion  dulness. 


close  to  the  ear,  and  accompanied  by  showers  of  the  sharp  metallic 
rales  above  described.  The  vocal  resonance  is  increased  over  these 
areas,  often  to  the  extent  of  bronchophony.  When  bilateral,  these  signs 
are  generally  more  marked  at  one  base,  and  often  there  is  definite 
con.solidation  found  at  one  base  and  only  metallic  rales  at  the  other. 
Sometimes  one  base  only  is  affected  when  the  signs  of  croupous  pneu- 
monia are  simulated,  but  in  such  cases  the  rales  in  the  consolidated 
area  are  generally  more  abundant  than  are  found  in  that  disease.  In 
some  cases  definite  signs  of  consolidation  never  appear,  and  a  diagnosis 
from  bronchitis  has  to  be  made  on  other  grounds  to  be  mentioned  here- 


BRONCHOPNEUMONIA  625 

after.  In  addition  to  the  rales,  a  fine,  superficial  pleural  rub  may  be 
audible  over  the  consolidated  areas. 

Course.— The  attack  lasts  a  variable  time  and  is  not  self-limited  as 
in  croupous  pneumonia,  except,  perhaps,  in  certain  rare  cases  of 
primary  bronchopneumonia.  Between  two  or  three  weeks  is  an 
average  duration  in  a  favorable  case,  and  the  signs  in  the  lungs 
usually  remain  another  ten  days  or  so.  The  dulness  becomes  less 
marked  and  gradually  clears,  the  bronchial  breathing  changes  through 
bronchovesicular  to  harsh  breathing  in  which  expiration  is  rather  loud 
and  prolonged,  and  from  this  to  normal.  The  last  to  disappear  are  the 
rales,  moist  or  dry,  which  remain  for  some  days  after  the  consolidation 
has  entirely  cleared,  accompanied  in  some  cases  by  w^eakness  of  the 
breath  sounds. 

Clinical  Varieties.  Protracted  Bronchopieumonia. — Cases  of  very  long 
duration  occur  often  after  measles  or  whooping-cough  and  generally 
end  in  death,  but  may  clear  up  either  partially  or  completely.  Some 
of  these  cases  begin  acutely  and  run  a  high  temperature  for  the  first 
few  weeks ;  some  are  indolent  from  the  outset  and  show  a  moderate 
temperature  range  and  rather  subacute  symptoms.  The  child  wastes 
steadily,  the  signs  persist  or  spread  slowly,  and  a  suspicion  of  tuber- 
culosis is  raised  or  even  a  diagnosis  of  that  disease  made.  In  some 
cases  the  signs  nearly  clear,  only  some  impairment  being  left  perhaps 
at  the  bases,  but  the  child  does  not  improve  and  continues  to  waste. 
Diarrhea  is  common,  the  finger-tips  become  glazed  and  perhaps  clubbed, 
the  eyelashes  grow  long;  the  skin  gets  harsh,  dry,  and  yellowish,  and 
often  becomes  covered  with  a  growth  of  downy  hair,  especially  down  the 
back.  Groups  of  fine  petechial  spots  in  the  skin  of  the  abdomen  some- 
times appear,  as  already  mentioned,  in  such  cases. 

All  these  signs  accompany  a  tuberculous  bronchopneumonia  with 
great  certainty,  but  the  same  are  found  in  a  protracted  bronchopneu- 
monia of  other  causation,  and  errors  of  diagnosis  between  the  two 
diseases  are  extremely  common.  In  many  cases,  indeed,  a  differential 
diagnosis  is  quite  impossible  without  a  careful  examination  of  the 
mucus  from  the  back  of  the  throat  for  tubercle  bacilli.  Two  or  three 
months  is  a  common  duration  for  a  protracted  bronchopneumonia, 
and  at  the  autopsy  a  dilated  bronchial  tree  with  some  fibrosis  around  it 
and  at  the  root  of  the  lung  are  found,  besides  more  or  less  broncho- 
pneumonic  consolidation  of  old  or  recent  standing.  In  cases  which 
recover  the  return  to  health  is  slow  and,  as  regards  the  lung,  often 
incomplete. 

Bronchopneumonia  Secondary  to  the  Infective  Fevers.  Measles. — 
These  cases  are  often  of  long  duration,  but  may  be  acute  like  those  of 
other  causation.  In  many  of  them  the  consolidation  is  lobar  in  distribu- 
tion, and  in  fatal  cases  wide  areas  of  moist  gray  or  pink  consolidation 
are  found  at  the  autopsy. 

Whooping-cough. — In  these  cases  the  whoop  often  disappears  during 
the  attack  to  reappear  with  convalescence,  though  the  cough  may 
remain  spasmodic  and  exliausting.  The  child  may  show  the  pufifiness 
40 


626  disea6e;s  of  the  RESPiRAroRV  tract 

of  the  face  so  eonnnon  in  who()j)in<::;-('ou<:;li  and,  if  the  broncliopneunionia 
conies  late,  the  exluiustion  from  tlie  original  disease  will  make  the 
prognosis  more  serious.  Bronchiectasis  and  fibrosis  of  the  lung  are 
conmion  sequehv  of  these  cases. 

DipJtthcria. — Nearly  all  cases  secondary  to  diphtheria  are  fatal. 
They  commonly  follow  laryngeal  diphtheria,  and  are,  hence,  found 
after  intubation  and  tracheotomy.  They  are  generally  caused  by  a 
spread  of  the  diphtheritic  process  down  the  bronchial  tubes  and  the 
diphtheria  bacillus  can  be  isolated  from  the  lung  in  a  proportion  of 
these  cases,  but  some  are  septic  and  due  either  to  an  unhealthy  trache- 
otomy wound  or  to  inhalation  of  foreign  particles  during  feeding. 

Septic  cases  are  of  necessity  fatal;  their  causes  are  various.  Among 
the  cases  tabulated  under  "etiology"  the  following  primary  lesions  were 
found:  Retropharyngeal  abscess  in  two,  abscesses  elsewhere  in  two,  a 
suppurating  umbilicus,  a  suppurating  patent  urachus,  ulceration  due 
to  a  foreign  body  in  the  esophagus,  and  a  suppurative  nephritis. 

Cases  following  athrepsia  and  coiKjeniial  si/philis  or  chronic  diarrhea 
are  of  bad  prognosis,  but  are  generally  overlooked;  the  symptoms  are 
often  suppressed  and  atypical,  the  disease  being  t)nly  a  terminal  infection. 
In  such  cases  the  pulse-respiration  ratio  should  draw  attention  to  the 
condition.  Some  of  the  diarrheal  cases  show^  ulcerative  colitis  at  the 
autopsy. 

Comphcations. — The  complications  of  bronchopneumonia  are  mainly 
infective  lesions  of  various  kinds  and  are  generally  of  fatal  termination. 
Otitis  mcdia\st\\e  least  serious  among  them, and  the  remumder, empi/ciiia, 
purulent  pericarditis,  purulent  peritonitis,  and  purulent  meningitis,  are 
still  more  common  complications  of  croupous  pneumonia  and  will  be 
iliseussed  under  the  heading  of  that  disease.  Abscess  and  f/angrenc  of 
the  lung  are  described  under  separate  headings.  In  addition,  I  have 
found  cellulitis  of  the  chest  wall  as  a  complication.  Bronchopneu- 
monia when  it  leads  to  death  is  generally  fatal  on  its  own  account, 
complications  l)eing  found  in  but  a  small  proportion  of  cases. 

Sequelae. — The  commonest  and  most  important  sequela*  of  this 
disease  are  bronchiectasis  and  pulmonary  fibrosis.  In  some  cases  the 
bronchiectasis  disappears,  but  in  others  a  permanent  dilatation  of  the 
tubes  remains. 

Diagnosis. — When  a  case  of  acute  disease  presents  itself  with  cough 
and  shortn(>ss  of  breath,  accompanied  by  fever  and  malaise,  our  atten- 
tion is  naturally  drawn  to  the  lungs  as  the  source  of  the  symptoms, 
and  we  expect  to  find  one  of  three  conditions — either  bronchitis,  broncho- 
pneumonia, or  croupous  pneumonia.  It  is,  then,  from  the  first  and  last 
of  these  that  l)ronchopneumonia  must  be  separated.  In  addition,  the 
bronchopneumonia  may  be  simple,  or  of  tuberculous  origin. 

Bronchitis. — From  acute  bronchitis  it  may  be  diagnosed  both  by 
symptoms  and  by  signs,  though  in  certain  cases  the  distinction  is  difficult 
or  even  impossible. 

The  onset  may  be  similar  in  the  two  diseases  and  helps  but  little; 
the  pulse-respiration  ratio  may  be  of  some  assistance,  the  disturbance 


BRONCHOPNEUMONIA  627 

of  respiration  being  generally  greater  in  bronchopneumonia,  and  if  the 
ratio  is  altered  as  far  as  2  :  1  this  disease  is  probably  present;  a  ratio 
of  3  :  1,  on  the  other  hand,  is  found  in  bronchitis,  but  only  with  exten- 
sive bronchitic  signs.  The  nature  of  the  cough  affords  little  help, 
and  dyspnea  and  cyanosis  are  merely  an  index  of  the  bronchitis  which 
occurs  in  both.  The  temperature  is  sometimes  of  importance  on 
account  of  its  different  duration  in  the  two  diseases,  but  is  of  no  value 
at  the  outset.  It  may  be  equally  high  in  both,  but  in  bronchitis  it 
generally  lasts  a  few  days  to  a  week,  whereas,  in  bronchopneumonia 
the  course  is  considerably  longer.  Diarrhea  may  occur  in  either  disease; 
constipation  is  seldom  found  with  bronchopneumonia,  but  sometimes 
occurs  with  bronchitis,  though  generally  in  older  children.  The  age  of 
the  patient  is  of  assistance  since  bronchopneumonia  is  a  disease  of 
infancy,  cases  above  the  age  of  three  years  only  occurring  occasionally 
as  a  secondary  affection.  Nervous  phenomena  are  rarely  seen  in 
bronchitis,  and,  as  a  rule,  the  patient  does  not  appear  so  acutely  ill  as 
in  a  case  of  bronchopneumonia;  this  is  often  an  important  point. 

The  early  signs  in  bronchopneumonia  are  those  of  bronchitis  only, 
and  occasionally  in  cases  diagnosed  on  other  grounds  no  signs  pointing 
to  consolidation  appear  in  the  lungs.  The  bases  behind  are  the  position 
at  which  such  signs  should  be  sought.  They  may  be  indicated  by 
sharp,  resonant  rales  of  a  metallic  quality,  no  further  signs  of  consolida- 
tion being  obtained;  but  generally  at  some  spot  dulness,  bronchial 
breathing,  and  bronchophony  appear  in  addition  to  the  fine  metallic 
rales  mentioned  above.  These  nearly  always  indicate  inflammatory 
consolidation,  but  occasionally  the  breath  sounds  may  be  bronchial 
or  approaching  bronchial  in  quality  over  an  area  of  firm  collapse  in 
bronchitis  only.  In  this  event  a  diagnosis  of  bronchitis  will  generally 
be  possible  on  other  grounds;  the  constitutional  symptoms  will  be  less 
acute,  and  the  suspected  area  will  clear  up  with  greater  rapidity. 

Lobar  Pneumonia.- — The  differential  diagnosis  will  be  discussed  under 
the  heading  of  that  disease  (p.  641.) 

Pulmonary  Tuberculosis. — Two  forms  of  tuberculosis  may  simulate 
bronchopneumonias  of  different  types.  Firstly,  acute  miliary  tuber- 
culosis may  be  difficult  to  distinguish  from  cases  of  acute  broncho- 
pneumonia, the  lung  symptoms  being  often  prominent  before  those  of 
the  meningitis  so  commonly  present  arise.  In  such  a  case  the  child  is 
acutely  ill,  and  the  lungs  are  filled  with  fine,  moist  rales,  together  with 
areas  of  consolidation  in  some  cases.  Usually  the  case  presents  a 
more  hopeless  aspect  than  does  one  of  simple  bronchopneumonia. 
The  child  is  often  poorly  nourished,  the  skin  is  cyanosed,  with  a  dark 
flush  sharply  confined  to  the  cheeks,  the  spleen  and  liver  are  often 
large  and  firm,  and,  as  a  rule,  meningeal  symptoms  soon  appear — 
drowsiness,  twitchings,  sudden  screamings,  and,  perhaps,  some  head 
retraction. 

Secondly,  protracted  bronchopneumonia  of  simple  causation  is  some- 
times indistinguishable  from  chronic  pulmonary  tuberculosis  in  young 
children,  this  being  indeed  a  bronchopneumonia  of  specific  causation. 


628  DISEASES  OF  THE  RESPIRATORY   TRACT 

In  such  cases  the  disease  spreads  by  the  lymphatics  from  caseous  nodes 
at  the  root  of  the  hmcr,  aiid  consecjucntly  the  most  marked  si<rns,  and 
those  first  to  ap{)ear,  are  in  the  intrascapuhir  region  behind,  more  often 
on  the  right  side.  This  distribution,  the  tendency  of  tlie  signs  to  persist 
and  spread,  the  physical  signs  of  softening  of  hmg  deposits,  when  such 
occurs,  and  the  signs  of  tubercle  elsewhere,  as  in  peritoneum,  intestine, 
spleen,  etc.,  may  give  the  clue  to  the  nature  of  the  condition.  Such 
general  symptoms  as  wasting,  dry  skin,  petechial  hemorrhages,  growth 
of  eyelashes  and  body  hair,  finger  clubbing,  or  even  some  edema  of 
extremities  may  occur  in  both  the  simple  and  the  tuberculous  disease; 
edema  more  often  accompanies  the  latter. 

Prognosis. — lliis  is  very  serious  in  all  cases  of  bronchopneumonia. 
Some  idea  of  the  mortality  among  hospital  cases  may  be  got  from  the 
table  appearing  under  etiology.  The  disease  is  much  less  common 
among  the  well-to-do  classes,  and  is  much  less  fatal.  It  will  be  seen 
that  the  mortality  appears  higher  among  the  primary  cases  and  those 
due  to  bronchitis  than  among  those  secondary  to  measles  and  whooping- 
cough.  This  is,  I  think,  due  to  a  somewhat  higher  age  average  among 
the  latter  cases.  Age  is  a  very  important  factor  in  prognosis,  and  next 
to  it  comes  the  general  health  and  nutrition  of  the  child,  especially  with 
regard  to  the  presence  of  rickets.  Diarrhea  is  a  serious  complication 
when  severe,  and  should  receive  prompt  treatment.  It  will  be  ol)served 
that  cases  secondary  to  athrepsia,  congenital  syphilis,  and  diarrhea  are 
nearly  always  fatal,  being  often  merely  a  terminal  infection.  Those 
accompanying  diphtheria  and  septic  lesions  owe  their  hopeless  aspect 
to  the  nature  of  the  original  disease. 

Treatment. — We  have  no  specific  treatment  for  this  disease.  That 
which  comes  nearest  to  it  is  the  treatment  with  full  doses  of  belladonna, 
after  the  manner  recommended  by  Dr.  J.  A.  Coutts.  The  drug  is  given 
in  doses  of  0.016  gm.  (|  gr.)  of  the  extract  to  infants  and  young  children, 
repeated  every  two  or  three  hours.  These  doses  cause  marked  flushing 
of  the  face,  thirst,  and  often  some  peevishness,  but  symptoms  of  poison- 
ing are  rare  and  never  serious.  The  drug  is  especially  valuable  in  cases 
where  bronchitis  of  the  small  tubes  is  a  marked  feature,  and  acts, 
probably,  by  controlling  the  secretion  and  thus  clearing  the  small  tubes, 
and  also  as  a  stimulant  to  the  respiratory  centre.  The  results  are  very 
striking  in  many  cases,  and  it  should  always  be  given  a  few  days'  trial. 
Small  doses  are  useless. 

In  cases  of  capillary  bronchitis,  or  where  the  secretion  in  the  tubes 
is  abundant  and  is  adding  to  the  dyspnea,  an  emetic  should  be  ordered 
at  the  start.  Ipecacuanha  wine  in  4  c.c.  (1  dr.)  doses,  or  ijx'cac- 
uanha  powder  in  0.6  gm.  (10  gr.)  doses  repeated  in  a  quarter  of  an 
hour,  if  necessary,  may  be  given,  assisted,  if  necessary,  by  tickling  the 
fauces  with  a  feather,  or  by  passing  a  soft  stomach  tube.  Vomiting 
is  sometimes  impossible  to  induce  in  these  cases. 

Counterirritation  of  the  chest  is  useful  in  cases  where  pulmonary 
collapse  is  suspected,  and  where  there  is  much  bronchitis.  It  may  be 
applied  either   by  stimulating   liniments,  or  with    a  mustard  or  Chili 


LOBAR  PNEUMONIA  g29 

paste.  This  may  be  reapplied  from  time  to  time  as  indicated.  It  is 
questionable  whether  cotton  and  wool  jackets  do  more  than  add  to  the 
difficulties  of  breathing. 

Fever  must  be  controlled  if  excessive,  but  antipyretic  treatment  is 
less  often  required  than  in  croupous  pneumonia.  Water  in  some  form 
is  the  best  antipyretic,  and  its  application  will  be  discussed  when  croupous 
pneumonia  is  considered.  It  must  be  used  with  caution  for  infants,  as 
their  vitality  is  easily  depressed,  and  its  application  must  be  considered 
dangerous  and  useless  in  cases  where  the  skin  is  not  well  flushed  with 
blood.  It  is  essential  that  there  should  be  a  reaction  after  bathing. 
When  the  surface  is  cold  and  the  rectal  temperature  high,  a  bath  at 
105°  to  110°  F.,  with  or  without  mustard,  15  gm.  to  4  litres  (^  oz.  to 
1  gallon),  will  bring  the  blood  to  the  skin  and  reduce  the  fever.  A  dose 
of  brandy  in  hot  water  will  assist  this  action. 

Many  cases  of  bronchopneumonia,  including  all  secondary  cases,  are 
in  need  of  stimulants  throughout,  and  of  these  whiskey  and  brandy  are 
the  most  satisfactory.  They  may  be  given  in  quantities  up  to  15  to 
30  c.c.  (^  or  1  oz.)  daily  to  a  child  of  one  year,  and  this  is  best  divided 
into  small  quantities  every  three  hours.  Strychnine  and  caffeine  are 
indicated  where  heart  failure  seems  likely  to  occur,  and  digitalis  is 
recommended  by  many. 

Diarrhea  must  be  treated  by  appropriate  feeding.  Careful  feeding 
will  in  many  cases  be  the  most  successful  method  of  management.  The 
milk  must  be  well  diluted,  as  with  barley-water,  and  may  be  previously 
digested  with  pepsin  or  pancreatin,  or  0.065  gm.  (1  gr.)  of  papain  with 
0.15  to  0.2  gm.  (2  or  3  gr.)  of  bicarbonate  of  soda  may  be  added  to 
each  feeding.  In  some  cases  albumen-water  (the  whites  of  two  or  three 
eggs  to  one  pint  of  water)  may  be  substituted  for  milk  during  twenty- 
four  hours  or  more.  A  dose  of  castor  oil,  followed  by  a  mixture  con- 
taining 0.15  to  0.2  c.c.  (2  or  3  ni)  of  the  same,  with  0.03  c.c.  (J  m.)  of 
tincture  of  opium  (for  a  child  of  one  year)  to  each  dose  may  be  effective. 

At  the  termination  of  the  attack,  or  in  persistent  cases  where  the 
temperature  is  low,  tonics  such  as  quinine  combined  with  small  doses  of 
iron  should  be  given.  Some  of  the  protracted  cases  are  much  benefited 
by  being  carried  into  the  open  air  when  weather  and  season  permit. 
In  any  case  the  child  should  be  moved  to  the  seaside  as  soon  as  he  is 
well  enough  to  travel. 

LOBAR  PNEUMONIA. 

Lobar  or  Croupous  Pneumonia,  the  common  pneumonia  of  adult  life, 
is  still  more  common  in  infancy.  All  recognize  its  occurrence  after 
infancy  is  past,  but  some,  up  to  the  present,  fail  to  realize  its  prevalence 
during  the  first  two  years  of  life.  The  reason  for  this  is  twofold.  First, 
that  the  disease  is  but  seldom  found  in  the  postmortem  room.  This  is 
explained  by  the  low  mortality  of  lobar  pneumonia  in  childhood,  and 
also  by  the  fact  that  when  death  does  occur  it  is  generally  due  to  com- 


630 


DISEASES  OF  THE  RESPIRATORY   TRACT 


plications,  the  original  lesion  liavino;  had  time  to  clear  up.  Second, 
because  cases  in  which  a  diagnosis  of  l()l)ar  pnciunonia  was  made  not 
infrequently  show  after  death  tlie  lesions  of  a  hroncliopneunionia  whh 
lobar  consolidation.  This  is  flue  in  part  to  the  difficulty,  amounting 
to  im])()ssil)ility  in  certain  cases,  of  diagnosing  between  these  two  con- 
ditions, but  also  in  part  to  the  fact  that  bronchojjuemnonia  is  not 
infrequently  a  fatal  conij)li(ation  of  lol)ar  pneumonia  in  infancy,  ^^hen 
this  occurs^  death  is  generally  delayed  until  long  after  the  lesions  of  the 
original  disease  have  entirely  disappeared. 

The  accompanying  chart  shows  the  relative  frequency  of  the  disease 
at  different  years  of  life  among  I'iW)  cases  collected  by  me.  It  will  be 
observed  that  the  greatest  numljcr  occur  at  the  age  of  two  years,  the 


Fin.  1?.'. 


m   <2 

Z 

AGE  IN  YEARS 

1 

2 

3 

1 

5 

G 

7 

8 

9 

10 

11 

12 

13 

14 

15 

50 
40 

30 

20 

10 
0 



' 1 





— 







-  1 

1 

/  \ 

\ 

\  i 





1 J 



1 1 













^—\- 

w 

' 





A  /    \     j 

\/     \ 

'   Y          \ 

\  1 

!          !          !          1 

; 



Chart  showing  relative  frequency  of  lobar  pneumonia. 


disease  becoming  less  and  less  frequent  with  advancing  years.  Pneu- 
monia, including  all  forms,  is  of  very  common  occurrence  in  infancy, 
and  25  per  cent,  of  the  cases,  at  a  low  estimate,  are  instances  of  lobar 
pneumonia  (Fig.   135). 

Etiology. — Lobar  pneumonia  is  a  primary  infective  disease  and  is 
never  secondary;  the  micro-organism  present  is  in  most  cases  the 
pneumococcus,  and  some  predisposing  cause  can  generally  be  discovered 
in  association  with  its  occurrence.  A  definite  history  of  exposure  is 
occasionally  obtained,  and  cold  is  probably  instrumental  in  lowering 
resistance.  Trauma  is  an  occasional  factor.  One  attack  of  pneumonia 
predisposes  to  subsequent  ones  in  children  as  in  adults,  and  in  older 
children  it  is  not  uncommon  to  obtain  a  history  of  one  or  more  such 
seizures  in  the  past.    It  is  sometimes,  but  rarely,  epidemic. 


LOBAR  PNEUMONIA 


631 


Morbid  Anatomy.— The  appearance  of  the  lung  in  lobar  pneumonia 
of  infancy  and  childhood  is  that  of  the  same  disease  in  the  adult,  save 
that  when  hepatization  is  established  the  cut  surface  is  less  coarsely 
granular,  owing  to  the  smaller  size  of  the  alveoli,. and  the  outline  of  the 
lobules  is  more  distinct. 

Histology. — The  microscopic  appearance  is  similar  to  that  found  in 
the  adult,  but  the  exudation  is  granular,  consisting  of  fibrin  and  serum. 

Symptomatology.  Onset. — The  onset  of  the  disease  is  sudden,  or  at 
least  rapid  in  nearly  all  cases.  The  most  common  initial  symptom  is 
vomiting;  this  generally  occurs  once  or  twice  only,  but  occasionally  it 
continues  for  the  first  few  days  after  food.  Chilliness  is  not  uncommonly 
complained  of,  but  a  rigor  is  distinctly  rare  in  childhood,  in  contra- 
distinction to  its  prevalence  in  adult  life.  Convulsions  are  uncommon 
at  the  onset  of  pneumonia,  even  in  young  infants,  but  they  may  occur, 
as  in  the  case  of  a  child  of  one  and  a  half  years  of  age  in  whom  four 
convulsive  attacks  occurred  during  the  first  day  of  the  disease.  Rapid 
breathing  is  one  of  the  earliest  changes  noticed,  and  often  directs  the 
attention  of  the  friends  to  the  chest  as  the  cause  of  illness.  In  many 
cases  the  alae  nasi  are  noticed  to  be  overactive.  In  children  old  enough 
to  indicate  its  presence  headache  is  usually  present,  sometimes  lasting 
for  days,  and  pain  in  the  side  is  often  complained  of.  This  is  generally 
thoracic,  but  is  often  abdominal,  and  may  simulate  that  of  appendicitis, 
peritonitis,  or  some  other  abdominal  disease,  as  in  the  case  of  a  young 
child  where  the  pain  was  paroxysmal  and  led  to  a  suspicion  of  intus- 
susception. 

Cough  is  generally  slight,  and  is  often  overlooked  by  the  parents  and 
friends;  it  is  seldom  distressing  or  frequent  as  in  bronchopneumonia, 
but  it  may  aggravate  the  pleural  pain  and  cause  the  child  to  scream 
or  cry  out  at  intervals.  It  is  dry  and  hacking  in  quality,  short,  and 
purposeless,  and  is  unaccompanied  by  expectoration.  Quite  commonly 
the  cough  does  not  appear  until  several  days  after  the  onset,  and  in  a 
few  cases  it  may  be  absent  throughout. 

Accompanying  these  definite  symptoms  are  others  more  general. 
The  child  is  drowsy  and  languid,  and  shows  a  disposition  to  be  nursed, 
and  in  young  children  the  power  of  walking  is  often  lost  temporarily. 
Food  is  refused,  but  thirst  is  intense,  and  cold  water  eagerly  demanded. 
The  child  avoids  the  light  and  is  peevish  if  roused,  sleep  is  disturbed, 
and  he  is  restless  at  night.  A  general  tenderness  of  the  body  to  handling 
is  found  in  some  cases. 

Constipation  is  an  interesting  feature  of  lobar  pneumonia;  it  is  found 
in  all  older  children  and  also  very  generally  in  infants,  in  contradistinction 
to  the  prevalence  of  diarrhea  as  an  accompaniment  of  bronchopneumonia. 
It  may  even  occur,  as  I  have  had  opportunity  to  observe,  in  a  child 
whose  motions  were  normally  loose. 

A  robust  child,  then,  to  take  a  typical  example,  is  suddenly  seized 
with  the  symptoms  already  mentioned.  He  presents  to  observation  a 
flushed  skin,  with  heavy  red  color  on  the  cheeks  and  bright,  shining 
eyes,  often  with  some  anxiety  of  expression.     The  tongue  is  thickly 


632  DISEASES  OF   THE  RESPIRATORY   TRACT 

furred  and  there  may  appear  some  herpes  at  the  side  of  the  mouth. 
Certain  symptoms  must  be  reviewed  in  more  detail. 

Dyspnea. — The  l)reathing  is  very  rapid,  and  the  alae  nasi  work 
vigorously.  The  respirations  are  often  50  or  ()0  per  minute,  and  may 
reach  SO  or  100  in  a  young  child.  The  normal  pulse-respiration  ratio 
is  disturbed  generally  to  3  :  1,  but  occasionally  to  2  :  1  or  even  \h  :  1. 
This  disturbance  is  of  value  before  the  lung  signs  have  a])j)eared,  but 
later  is  not  such  a  valuable  diajjnostic  feature  in  childhood  as  in  adult 
life,  since  it  occurs  also,  to  a  great  extent,  in  other  severe  respiratory 
affections.  In  slight  attacks  of  lobar  pneumonia  the  puLse-respiration 
ratio  may  be  but  little  disturbed.  The  (juality  of  the  respirations  is 
as  peculiar  as  is  their  rapidity.  There  is  a  distinct  pause  at  the  end 
of  inspiration,  and  expiration  is  accompanied  by  a  grunt,  or  occasionally 
a  groan.  In  some  cases  this  grunt  becomes  a  short  cough,  and  is  then 
very  distressing  and  leads  to  much  exhaustion.  Though  the  respirations 
are  rapid  there  is  often  no  distress,  ijut  if,  as  rarely  happens,  the  avail- 
able respiratory  surface  is  greatly  reduced  there  is  cyanosis,  and  the 
child  lies  propped  up  in  bed  with  an  anxious  eye,  all  his  attention  being 
expended  on  his  respiratory  functions.  Such  conditions  of  marked 
dyspnea  are  more  often  observed  in  bronchopneumonia. 

Skin. — The  skin  is  hot,  dry,  and  pungent  to  the  touch,  a  condition 
common  to  this  disease  and  to  scarlet  fever.  There  is  no  sweating 
until  the  crisis  is  past,  when  it  may  be  profuse,  but  is  generally  less 
noticeable  in  children  than  in  adults. 

Herpes  labialis  may  occur  with  pneumonia  in  children,  generally  in 
mild  cases,  but  it  is  less  common  than  in  adults.  Schlesinger  found  it 
in  18  per  cent,  among  173  cases.  A  slight  icteric  tinting  of  the  skin 
and  conjunctiva  is  occasionally  present,  and  jaundice  occurs  in  some 
cases. 

Urine. — The  urine  is  scanty  and  concentrated  and  there  is  generally 
a  diminution  or  even  absence  of  chlorides,  as  in  pneumonia  of  the  adult. 
Albumin  Is  found  in  a  proportion  of  the  cases,  according  to  Schlesinger 
in  28  per  cent. 

Temperature.— The  temperatUTe  rises  abruptly,  so  that  in  a  few  hours 
it  registers  104°  or  even  105°  F.  At  this  point,  or  thereabouts,  it  remains 
throughout  the  attack,  with  remissions  of  1^>°  to  2°  in  typical  cases, 
though  more  marked  remissions  of  3°  or  4°  may  occur,  and  are  more 
common  the  younger  the  patient.  Rarely,  it  swings  like  a  hectic  tem- 
perature, antl  this  in  cases  which  present  no  other  peculiarities.  On 
observing  such  a  chart  we  must  be  sure  that  the  oscillations  are  not  the 
result  of  sponging  to  reduce  fever. 

The  Crisis. — At  the  crisis  the  temperature  falls  rapidly  from  a  high 
level  to  normal  or  subnormal;  thus  it  may  drop  from  105°  to  97°  F.  within 
twelve  to  eighteen  hours.  Verv  commonly  the  temperature  falls  to 
near  normal  on  the  day  before  the  true  crisis  and  rises  again.  After 
the  crisis  the  temperature  remains  subnormal  with  fluctuations  of  less 
than  2°  for  a  few  days,  and  then  becomes  normal.  When  the 
crisis  appears  the  pulse  and  respiration  rapidly  resume  the  ratio  of 


LOBAR  PNEUMONIA 


633 


health,  and  the  patient,  from  a  condition  of  considerable  distress,  very 
quickly  regains  a  state  of  comfort.  The  time  at  which  the  crisis  appears 
varies  considerably.  The  accompanying  chart  (Fig.  137)  shows  the 
incidence  among  eighty-six  cases  collected  by  myself. 


Fig. 

136 

MONTH 

February                                                                                                                1 

DAY 

23 

'24 

25 

2« 

27 

28 

2U 

30 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

104° 

_   103° 
1    102° 
"g    101° 
1    100° 

98 
97° 

A 

- 

" 

^ 

^ 

1 

1 

5 

J 

^ 

I 

^ 

I 

\ 

\, 

1 

\/ 

1 

1 

\ 

V 

4 

i 

N 

^ 

^ 

\ 

\ 

\ 

> 

( 

\ 

r 

\ 

^ 

y 

^ 

^ 

s/ 

^ 

■• 

"\ 

/ 

^ 

V 

/ 

\ 

r 

M 
PULSE   _ 

^-^ 

.^VA 

150.^- 

150, '■ 

152,-' 

100,-' 

llj,"-" 

112.-' 

132,-' 

120,-' 

,-" 

RESP.    " 

y 

^U 

50,- 

10.- 

JO,-- 

40,-' 

50,-- 

23,-' 

3C,-' 

30,-' 

,-' 

-    ,. 

-' 

- 

Temperature  chart,  ease  of  lobar  pneumonia. 


Fig. 137 


< 

DAYS  OF  DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

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Chart  showing  day  of  crisis  in  eighty-six  cases  of  lobar  pneumonia. 

Probably  more  abortive  cases  of  pneumonia  occur  in  children  than 
in  adults,  but  their  prevalence  is  hard  to  estimate.  In  some  cases  the 
attack  lasts  but  one  or  two  days,  the  lung  condition  never  parses  beyond 
the  stage  of  engorgement,  and,  in  the  absence  of  physical  signs,  the 


G34  DISKASI'S  OF   THE  RESPIRATORY   TRACT 

nature  of  the  condition  often  remains  uiurcognized.  With  regard  to 
the  frecjueney  of  a  erisis  in  lohar  j)n<'nnu)nia  of  eliihhvn,  I  find,  among 
cases  collected  by  myself,  that  during  the  hrst  year  of  life  'A'y  per  cent, 
ended  so,  and  during  the  second  year  31  per  cent.  Among  192  cases 
of  all  ages  up  to  fourteen  years,  <S0,  or  45  per  cent.,  ended  by  crisis, 
so  that  it  apj)ears  to  occur  in  nearly  half  the  cases  of  croupous  pneu- 
monia in  childhood. 

Physical  Signs. — These  vary  according  to  the  stage  of  the  disease  at 
which  the  case  comes  under  observation.  At  the  onset  nothing  abnormal 
is  found  in  the  chest,  and  this  nuist  not  be  allowed  to  throw  doubt  upon 
the  diagnosis,  which  can  generally  be  determined  on  other  grounds. 
Indeed,  it  generally  happens  that  the  signs  do  not  appear  for  some 
days  after  the  onset,  and  they  may  even  be  delayed  until  the  crisis  is 
past.  This  delayed  appearance  of  physical  signs  has  been  explained 
on  the  supposition  that  in  childhood  the  jirocess  often  begins  in  the 
central  portions  of  the  lung  and  gradually  sj)rea(ls  thence  to  the  surface. 
This  sujiposition  is  untenal)le,  since  consolidation,  when  covered  by 
healthy  lung  tissue,  does  not  give  rise  to  the  weak  breathing  so  commonly 
noticed  at  the  first  sign  of  pneumonia,  as  may  be  proved  by  listening 
at  the  lung's  apex  in  front  in  cases  where  consolidation  is  confined  to 
the  posterior  portions.  Under  these  circumstances  is  heard  harsh 
breathing,  due  to  the  overacting  lung  tissue  in  front,  and,  through  this, 
distant  bronchial  breathing  from  the  solid  area  behind.  More  probably 
the  tardy  aj)pearance  of  signs  depends  on  a  true  delay  in  passing  from 
the  stage  of  congestion  to  that  of  definite  consolidation. 

The  earliest  sign  to  be  found  is  a  weakening  of  the  breath  sounds, 
which  may  progress  for  two  or  three  days  until  breathing  is  almost 
entirely  suppressed  before  it  becomes  tubular.  This  diminution  is 
probably  due  to  restricted  expansion  of  the  lung,  owing  to  vascular 
engorgement.  A  little  later  a  rise  in  tone  of  the  percussion  note  may  be 
appreciated,  and,  therewith,  often  some  accentuation  and  lengthening 
of  the  expiratory  sound,  and  slight  increase  of  vocal  resonance. 

When  consolidation  is  fully  established  the  following  signs  are  present. 

Inspection. — If  the  consolidation  involves  a  large  area  of  lung  tissue 
some  loss  of  mobility  on  the  affected  side  will  be  observed. 

Palpafion  and  Percussion.  With  the  hand  laid  upon  the  chest  wall 
this  impaired  movement  may  be  clearly  appreciated,  and  occasionally 
a  friction  rub  or  intrapulmonary  rfdes  may  be  felt.  Vocal  vibration  is 
not  obtainable  in  young  children  owing  to  the  treble  quality  of  the 
voice.  On  percussion  over  the  consolidated  area  a  high-pitched,  im- 
paired, or  dull  note  is  obtained,  and  the  finger  appreciates  some  increase 
of  the  normal  resistance.  This  varies  much  according  to  the  amount 
of  consolidation  present.  As  a  rule,  the  resistance  is  not  such  as  to 
suggest  the  presence  of  fluid,  but  occasionally,  if  the  consolidation  is 
extensive,  the  resistance  and  dulness  may,  to  some  extent,  simulate  that 
of  effusion.  When  this  is  so,  it  is  sometimes  due  to  a  layer  of  fluid 
outside  the  solid  lung,  but  not  always.  Around  the  consolidated  area 
the   percussion   note  shades   off  gradually  into   that  of  healthy   lung. 


LOBAR  PNEUMONIA 


635 


though  the  note  may  be  "boxy"  over  clear  areas.  Occasionally,  the 
percussion  note  may  be  truly  tympanitic  over  the  pneumonic  lung,  and 
this  more  commonly,  I  think,  when  the  process  involves  the  apex 
(Fig.  138).  _ 

Auscultation. — The  breath  sounds  at  the  very  commencement  are 
partially  suppressed,  as  already  pointed  out;  later  they  are  harsh  in 
quality  with  prolonged  expiration,  and  soon  the  expiration  becomes 
truly  bronchial  while  the  inspiration  remains  vesicular,  a  condition  to 
which  the  term  bronchovesicular  is  sometimes  applied.  When  con- 
solidation is  fully  established,  high-pitched,  whiffy  bronchial  breathing, 
both  inspiratory  and  expiratory,  is  heard,  often  very  intense  and  near 


Fig.  138 


Lobar  pneumonia  in  a  girl  of  fourteen  months ;  shaded  area  represents  the 
consolidated  lung  and  the  dots  the  crepitations. 

at  hand,  but  occasionally  soft  and  distant.  It  is  accompanied  by  a 
shower  of  sharp,  consonating  rales  of  medium  size,  occurring  mostly 
at  the  end  of  inspiration.  The  fine-hair  crepitation  of  adults  is  but 
seldom  heard  in  childhood. 

Occasionally,  on  listening  over  the  consolidated  area,  nothing  but 
suppressed  breathing  is  noted  until  the  child  coughs  or  cries,  when, 
for  a  short  time,  intense  bronchial  breathing  and  sharp  rales  appear, 
and  again  give  place  to  weak  breathing.  This  indicates  a  blocking  of 
the  larger  tubes  with  secretion,  and  in  some  cases  of  massive  consoli- 
dation the  breath  sounds  may  remain  suppressed  for  some  days,  giving, 
with  the  marked  dulness  and  increased  resistance  to  percussion,  a  close 
resemblance  to  the  sims  of  effused  fluid. 


636  DISEASES  OF    THE   RESPIRATORY    TRACT 

Though  the  sharp  inspiratory  rales  mentioned  above  are  very  char- 
acteristic, (piite  commonly  no  added  sound  is  audible  over  the  con- 
solidated area,  or,  at  most,  a  sharp  click  at  the  end  of  inspiration,  and 
no  further  added  sound  than  this  may  be  found  from  first  to  last  in 
some  causes.  Over  the  rest  of  the  lungs  the  breath  sounds  are  normal 
or  perhaps  somewhat  exaggerated;  in  some  cases  there  are,  in  addition, 
scattered,  dry,  bronchitic  sounds.  Although  the  jjlcura  is  invariably 
inHamed  over  the  pneumonic  area  a  definite  friction  rub  is  not  often 
to  be  detected.  \Vhen  present  it  is  fine  in  cjuality,  and  is  often  difficult 
to  distinguish  from  the  accompanying  intrapulmonary  sounds. 

Vocal  resonance  is  increased  over  the  consolidated  area,  often  intense 
anil  bronchophonic.  When  the  process  is  at  the  ba^e  of  the  lung  the 
scapular  angle  is  generally  the  point  of  most  intense  conduction.  In 
some  cases  increase  of  vocal  resonance  is  the  only  discoverable  sign  of 
consolidation. 

Resulution. — When  the  temperature  has  fallen,  either  by  crisis  or 
more  gradually,  the  lung  consolidation  clears  up  with  great  rapidity,  so 
that  generally  in  three  to  five  days  the  lung  is  either  (juite  normal  to 
examination  or  there  is  left  only  slight  impairment  and  deficient  air 
entry  with  a  few  rales,  all  of  which  disappear  a  few  days  later.  There 
is  no  expectoration  as  in  the  adult  and  but  little  cough,  the  whole  being 
removed  by  liquefaction  and  absorption.  Occasionally  resolution  is 
delayed,  and,  rarely,  it  may  then  be  incomplete  and  leave  behind  some 
amount  of  pulmonary  fiV)rosis. 

Position  of  Lesion. — In  lobar  pneumonia  the  process  commonly 
follows  the  lobar  arrangement  of  the  lungs.  Consequently  the  position 
of  the  lesion  is  more  accurately  indicated  by  naming  the  lobe,  upper 
or  lower,  in  which  it  occurs  than  by  speaking  of  apex  and  base  in  this 
connection.  When  the  upper  lobe  is  affected  the  consolidation  is 
mainly  in  front  and  reaches  down  to  the  third  space  or  fourth  rib;  it 
is  generally  found  also  at  the  apex  of  the  axilla,  and  behind  involves 
only  the  suprascapular  region.  AMien  the  lower  lobe  is  involved  the 
signs  are  mostly  or  entirely  behind,  over  the  base  of  the  chest,  reaching 
upward  perhaps  nearly  to  the  scapular  spine;  they  extend  round  the 
side  to  the  midaxilla  at  the  base,  but  seldom  farther  forward,  and  are 
not  rarely  confined  to  the  posterior  aspect.  The  middle  lobe  on  the 
right  side  is  not  commonly  involved  in  lobar  pneumonia. 

Among  129  cases  of  lobar  pneumonia  in  children  of  all  ages  analyzed 
by  mvself  the  following  distribution  occurred: 

Right  Lung.  Left  Lung. 

Upper  lobe 40       Upper  lobe 10 

Lower  lobe 21       Lower  lobe 51 

Whole  lung 3 

Both  lungs 4 

Thus  it  appears  that  the  left  lower  lobe  is  the  most  frequent  seat  of 
disease,  and  after  this  the  right  upper  lobe  which  was  affected  four 
times  as  often  as  the  left  upper  lobe.  The  right  and  left  sides  were 
affected  in  a  nearly  equal  number  of  cases,  in  59  per  cent,  in  the  lower 


LOBAR  PNEUMONIA  637 

lobes  and  41  per  cent,  in  the  upper  lobes.  It  is  thus  apparent  that 
apical  pneumonia  is  quite  common  in  childhood,  and  this  is  especially 
the  case  in  infancy. 

Other  Organs.  Heart. — In  children  massive  consolidation  of  a  lower 
lobe  will  generally  displace  the  heart  somewhat,  and  this  must  be  borne 
in  mind  when  a  diagnosis  between  solid  lung  and  pleural  effusion  has 
to  be  made.  As  in  adults  the  impervious  condition  of  the  pneumonic 
lung  throws  a  strain  upon  the  pulmonary  circulation,  but  in  children 
this  is  generally  well  borne.  The  cardiac  muscle  is  generally  of  good 
quality,  and  the  right  ventricle  proportionately  stronger  than  in  later 
life.  In  fetal  life  the  pressure  in  the  right  and  left  sides  of  the  heart  is 
equal  and,  hence,  the  muscular  development  of  the  right  ventricle  no 
less  than  that  of  the  left,  and  this  powerful  right  heart  remains  through 
the  earlier  years  of  childhood  and  is  of  signal  value  when  lung  con- 
solidation occurs.  When  dilatation  appears  it  often  affects  the  heart 
as  a  whole,  generally  as  a  result  of  the  high  temperature,  and  the  poisons 
of  the  disease.  It  may  be  considerable  without  giving  rise  to  any  symp- 
toms. Any  failure  of  the  right  heart  is  indicated  by  an  increase  of 
dulness  beyond  the  normal  finger's  breadth  (deep  dulness)  to  the  right 
of  the  sternum,  and  therewith  an  alteration  in  quality  of  the  heart's 
first  sound,  perhaps  a  soft  systolic  murmur  or  reduplication.  If  the 
disability  is  great  the  heart's  pause  may  be  shortened,  giving  a  rhythm 
like  that  of  the  fetal  heart,  and  therewith  the  pulmonary  second  sound 
loses  its  accentuation.  These  are  very  serious  signs,  and  will  be  accom- 
panied by  obvious  symptoms  of  distress. 

The  abdomen  may  be  distended  somewhat  and  tympanitic.  The  liver 
and  spleen  are  generally  somewhat  swollen,  the  latter  sometimes 
palpable,  owing  to  the  changes  brought  about  by  the  high  temperature 
ancl  the  poisons  of  the  disease. 

Clinical  Varieties.  Relapsing  Pneumonia. — Cases  of  relapse  in  lobar 
pneumonia  are  not  very  common,  but  occasionally  occur.  After  the 
crisis  the  temperature  remains  subnormal  for  a  few  days,  generally 
three  to  five,  and  then  the  attack  is  repeated  and  another  crisis  occurs. 
Only  one  relapse  may  occur,  but  occasionally  three  or  four  are  seen 
and  they  generally  tend  to  get  shorter.  During  each  attack  a  separate 
area  of  lung  is  affected,  often  at  a  distance  from  that  formerly  involved ; 
thus  in  a  child  of  two  years  the  consolidation  began  in  the  left  upper 
lobe,  and  in  three  relapses  following  the  right  upper  lobe,  the  left  upper 
lobe,  and  the  left  lower  lobe  were  respectively  attacked  (Fig.  139). 

Spreading  and  Double  Pneumonia.— In  cases  where  new  areas  of 
consolidation  occur,  whether  on  the  same  or  opposite  side,  the  outlook 
is  rendered  more  serious.  As  a  rule,  the  opposite  lung  is  attacked,  and 
not  uncommonly  an  effusion  arises  on  one  or  other  side  in  these  douJDle 
cases.  The  duration  of  the  attack  is  in  any  case  prolonged,  the  crisis 
being  delayed  to  the  twelfth  or  fourteenth  day. 

Abortive  Pneumonia.— This  variety  is  more  common  in  children  than 
in  adults.  The  symptoms  of  an  ordinary  onset  occur,  and  then,  often 
before  any  physical  signs  have  appeared,  a  crisis  occurs  and  the  child 


63S 


DISEASES  OF    THE   h'ESrihWTORY    TRACT 


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lifjjht  ehantjes  are  found  in  one  hint;, 
ir,  and  the  diaj^nosis  lias  to  he  made 
in  their  ahsenee  and  remains  con- 
jeetural  only.  No  doubt  in  practice 
the  term  "fehrieula"  covers  a  mul- 
titude of  sueh  eases.  It  is  ])r()l)al)le 
that  the  process  in  the  lun<j;  may  he 
arrested  in  the  stage  of  engorifement 
and  never  proceed  to  hepatization. 
Pneumonia  irifh  effusion  will  he 
described  under  complications;  it 
miii^ht  with  ecpud  justice  be  included 
under  the  present  heading. 

Pneumonia  icith  Cerebral  Symp- 
toms.— These  ca.ses  are  very  puzzling 
and  often  tempt  the  unwary  to  a 
diagnosis  of  meningitis,  'l^he  -symj)- 
toms  are  various,  and  include  intense 
headache  and  nervous  irritability, 
coma  and  head  retraction,  twitcli- 
ings,  and  convulsions,  either  gen- 
eral or  confined  to  one  side.  These 
plx'nomena  generally  occur  at  the 
beginning  of  the  attack  and  disap- 
pear when  the  physical  signs  in  the 
lung  become  evident,  but  they  may 
last  until  the  crisis  be  past.  It  is 
well  in  such  cases  to  examine  the 
tym])anic  membrane  carefully,  for 
not  unconnnonly  the  nervous  symp- 
toms depend  upon  an  accompanying 
otitis  media  and  only  disapj)ear 
when  this  complication  is  recognized 
an<l  treated.  Cerebral  symptoms 
are  not  more  commoii  with  apical 
than  with  basal  consolidation. 

Complications. —  When  at  the  ex- 
j)ected  time  no  crisis  apj)ears  and 
the  temperature  remains  high,  some 
cau.se  for  this  must  be  carefully 
sought.  A  spread  of  the  disease  in 
the  lung  may  be  responsible,  but, 
a])art  from  this,  one  of  tlie  following 
complications  may  l)e  present. 

Teething. — Occasionally,  in  in- 
fants, a  troublesome  tooth  may  be 
the  explanation.  In  such  a  case 
the  temperature  may  swing  and  take 


LOBAR   PNEUMONIA 


639 


a  very  irregular  course  throughout  the  attack,  its  duration,  besides,  being 
unduly  prolonged. 

^  Otitis.— Much  more  commonly  otitis  media  is  the  cause  of  the  con- 
tinued temperature.  This  is  a  common  complication  of  pneumonia  of 
all  kinds  in  infancy,  and  not  infrequently  delays  the  crisis  in  lobar 
pneumonia.  Sometimes,  in  such  an  event,  the  temperature  makes  wide 
fluctuations,  but  it  may  remain  continuous,  after  the  type  of  the  pneu- 
monic temperature,  its  persistence  beyond  the  usual  period  being  the 
only  noticeable  feature.  Not  infrequently  I  have  observed  the  crisis, 
delayed  until  then,  follow  immediately  on  a  successful  puncture  of  the 
tympanic  membrane.  As  a  rule,  the  otitis  runs  its  course  with  the 
pneumonia,  but  occasionally  it  precedes  it  and  is  then,  perhaps,  a  causa- 
tive factor  in  the  attack,  since  the  pneumococcus  is  a  common  cause  of 
otitis  in  childhood. 

Pleurisy.— Dry  pleurisy  with  the  formation  of  fibrin  over  the  con- 
solidated area  occurs  in  all  cases,  and  gives  rise  to  no  symptoms  beyond 
the  occurrence  of  pain  during  the  attack  and  subsequent  adhesion  of 
the  pleural  surfaces.  Occasionally  the  pleurisy  may  attain  more  im- 
portant dimensions,  and  result  in  effusion  either  serous  or  purulent. 
In  many  cases  clear  fluid  is  poured  out  between  the  surfaces,  and  may 
remain  localized  by  adhesions  giving  rise  to  wooden  dulness  and  feeble 
breath  sounds  over  the  pneumonic  area;  it  is  ultimately  absorbed  and 
causes  only  a  tardy  resolution.  When  an  effusion  arises  the  crisis  is 
often  delayed  until,  perhaps,  the  twelfth  or  fourteenth  day,  and  there- 
after a  slight  temperature  is  maintained  by  the  pleural  inflammation  for 
a  while.  If  the  fluid  is  removed  with  the  aspirator  this  will  often  bring 
about  a  crisis  which  has  been  delayed  up  to  that  point.  Dulness  and 
perhaps  pleural  friction  remain  for  a  week  or  two  after  the  crisis.  Though 
the  fluid  is  generally  encapsulated  it  may  be  free  in  the  pleural  cavity, 
and  occasionally  with  an  apical  pneumonia  accumulates  at  the  base 
below  it.  Pleural  effusion  is  not  uncommon  on  one  or  other  side  when 
the  pneumonia  is  double. 

Often  the  fluid  drawn  off  is  somewhat  turbid,  and  is  found  micro- 
scopically to  be  filled  with  pus  cells.  This  will  naturally  cause  anxiety 
as  to  the  outcome,  whether  it  will  clear  up  like  a  serous  effusion  or 
progress  to  the  formation  of  an  empyema.  My  experience  has  been 
that  such  fluid  is  not  uncommonly  absorbed,  or  at  least  the  patient  may 
escape  with  no  more  serious  operation  than  aspiration.  Eiiipi/ema  is  a 
more  serious  complication  to  deal  with  and  is  accountable  for  a  large 
number  of  deaths  in  croupous  pneumonia  of  children.  In  many  cases 
it  is  probably  present  from  the  outset. 

Bronchopieumonia. — This  is  a  common  complication  in  the  first  two 
or  three  years  of  life  and  not  infrequently  leads  to  a  fatal  issue.  In  some 
cases  there  is  a  definite  crisis  and  bronchopneumonia  occurs  subse- 
quently, but  often  the  temperature  never  falls  and  a  case  which  began 
as  a  lobar  pneumonia  progresses  as  a  bronchopneumonia.  The  process 
often  starts  in  the  affected  lung  and  a  centre  of  hepatization  may  some- 
times  be   found   surrounded   by   areas   of  bronchopneumonia.     It  is 


640  DISEASES  OF   THE  RESPIRATORY   TRACT 

probable  that  often,  where  a  croupous  pneumonia  is  (Hagnosed  and  only 
bronchopneumonia  found  at  the  autopsy,  the  disease  was  really  a 
lobar  pneumonia  at  the  outset,  and  the  hepatization  ha^  cleared  up, 
leaving  to  view  only  the  bronchopneumonic  complication  which  led  to 
death. 

Purulent  Pericarditis. — This  is  an  occasional  cause  of  death  and 
cither  occurs  by  itself  or  more  commonly  in  conjunction  with  empyema. 
It  may  be  suspected  in  some  cases,  but  is  not  very  often  diagnosed  during 
life.  The  quantity  of  pus  is  seldom  great  and,  in  the  supine  or  semi- 
supine  position,  gravitates  to  the  back  of  the  heart  whose  apex  swims 
forward  into  contact  with  the  chest  wall.  Consequently,  the  sounds  are 
not  muffled  and  the  increase  of  cardiac  dulness  may  be  hardly  appreci- 
able. Moreover,  a  friction  rub  is  very  rarely  present.  The  most  valuable 
guide  to  the  diagnosis  of  this  condition  is  the  marked  general  and 
respiratory  distress  which  are  out  of  all  proportion  to  the  lung  condition 
present,  and  generally  lead  to  orthopnea.  Of  physical  signs  the  cardiac 
dulness  is  the  most  valuable.  If  it  extends  well  outside  the  apex  beat 
in  the  fifth  space  (in  the  fourth  space  this  is  of  no  value,  as  it  often 
does  so  here  in  dilatation),  if  it  rise  to  the  second  rib,  and  stretch  well 
to  the  right  of  the  sternum  in  the  fifth  space,  and  if  there  is  appreciable 
resistance  to  percussion — these  are  signs  of  great  value,  but  they  are 
often  absent. 

Pundent  Peritonitis. — When  purulent  peritonitis  occurs  as  a  compli- 
cation it  is  generally  only  part  of  a  widespread  infection  of  the  serous 
membranes,  a  pneumococcic  polyorrhomenitis,  and  adds  little  or  nothing 
to  the  symptomatology,  being  on  this  account  often  overlooked. 

Pundent  meningitis  is  of  occasional  occurrence,  generally  in  asso- 
ciation with  some  of  the  other  pus  complications.  It  is  perhaps  more 
often  suspected  than  found  owing  to  the  occurrence  of  pneumonia  with 
cerebral  symptoms,  but  in  these  cases  the  symptoms  occur  early  in  the 
disease.  When  they  are  of  late  onset  they  are  generally  due  to  menin- 
gitis. 

.Ibsccss  and  gangrene  of  the  lung  are  rare  complications  and  are 
described  under  separate  headings. 

Sequelae. — These  are  usually  not  of  a  serious  nature  and  often  only 
temporary  in  character.  Bradycardia  often  occurs  in  older  children, 
the  pulse  dropping  to  ()0  or  less  and  recovering  itself  again  during 
convalescence.  Some  amount  of  cardiac  asthenia  may  be  left  in  anemic 
and  weakly  children  but  seldom  gives  much  trouble.  Pulmonary 
fhrosis  is  a  rare  sequel  to  lobar  pneumonia  and  is  probably  the  most 
serious  that  may  occur;  it  is,  however,  far  less  common  than  after 
bronchopneumonia.  Recurrence  of  pneumonia  is  not  uncommon; 
among  hospital  cases  in  older  children  a  history  of  previous  attacks 
can  be  obtained  in  a  certain  proportion.  Sometimes  a  great  many 
recurrences  occur.  Cases  of  pulmonary  fibrosis  with  recurrent  acute 
attacks  must  not  be  mistaken  for  or  included  among  these. 

Diagnosis. — This,  in  young  children,  is  sometimes  a  very  difficult 
matter.     At  the  onset  the  most  striking  resemblance  exists  to  scarlet 


LOBAR   PNEUMONIA 


641 


fever;  when  consolidation  has  appeared  two  other  pulmonary  diseases 
have  to  be  considered.  On  the  one  hand  are  cases  of  bronchopneumonia 
with  lobar  consolidation;  on  the  other  pleural  effusions  whose  signs  are 
sometimes  indistinguishable  (I  speak  advisedly)  from  those  of  solid 
lung. 

Scarlet  Fever.— The  onset  of  pneumonia  often  resembles  that  of 
scarlet  fever  very  closely.  Vomiting,  headache  and  fever,  with  a  dry, 
burning  skin,  are  common  initial  symptoms  in  both,  and  many  points 
require  consideration  before  a  conclusion  can  be  arrived  at.  The 
tongue  is  furred  in  both  conditions,  but  the  raw,  red  tip  and  sides  and 
the  swollen  papillae  in  scarlet  fever,  especially  when  taken  with  the  dry, 
red  lips,  may  be  of  assistance.  Sore  throat  is  strong  evidence  in  favor 
of  scarlet  fever.  The  dry,  pungent  skin  belongs  to  both  scarlet  fever 
and  pneumonia,  and  it  is  this,  in  many  cases,  which  leads  to  doubt.  A 
passing  erythema  may  be  seen  with  pneumonia,  but  not,  of  course,  the 
persistent  punctiform  rash  of  scarlet  fever.  It  is  generally  before  the 
eruptive  period  that  doubt  exists.  jNIuch  the  most  important  diagnostic 
point  is  one  on  the  side  of  pneumonia,  namely  symptoms  pointing  to  the 
respiratory  system.  Rapid  respirations  accompany  high  fever  of  any 
causation,  but  the  disturbed  pulse-respiration  ratio  with  expiratory 
grunt,  working  alae  nasi,  and  often  some  cough,  point  to  pneumonia. 
In  scarlet  fever  it  is  the  pulse  that  is  especially  rapid;  in  pneumonia, 
the  respiration. 

Bronchojpneumonia. — Cases  of  primary  bronchopneumonia  often 
present  a  sudden  onset  closely  similar  to  lobar  pneumonia;  secondary 
bronchopneumonia  is  not  likely  to  lead  to  mistake,  as  it  is  preceded  by 
bronchitis  of  the  larger  tubes  and  often  follows  one  of  the  exanthemata. 
In  a  case,  then,  with  sudden  onset  in  a  young  child  the  question  of 
diagnosis  may  arise,  and  it  must  be  borne  in  mind  that  bronchopneu- 
monia is  uncommon  after  the  age  of  three  years.  If  the  lung  signs  are 
those  of  a  scattered  bronchitis  with  patches  of  consolidation  at  both 
bases  behind,  a  diagnosis  of  bronchopneumonia  will  be  readily  arrived 
at;  if  consolidation  is  confined  to  one  apex,  on  the  other  hand,  lobar 
pneumonia  may  be  accepted  with  great  certainty.  These  are  the 
extremes  which  leave  little  room  for  doubt,  but  if  there  is  marked 
consolidation  at  one  base  many  nicer  points  of  distinction  require 
consideration. 

Inspection,  palpation,  and  percussion  give  no  help.  The  character  of 
the  breath  sounds,  moreover,  offers  no  distinction,  but  if  they  are 
unaccompanied  by  rales  it  is  almost  certainly  a  lobar  pneumonia,  and 
if  the  rales  are  few  in  number  it  probably  is;  on  the  other  hand,  if  they 
are  abundant  and  spread  beyond  the  limits  of  the  consolidated  area, 
it  is  more  probably  a  bronchopneumonia.  Rales  elsewhere  over  the 
chest  must  be  looked  upon  with  suspicion,  though  they  may  occur  with 
lobar  pneumonia,  and  in  all  cases  of  doubt  the  appearance  of  sharp 
rales  or  consolidation  elsewhere,  especially  at  the  opposite  base,  must 
be  looked  for  to  confirm  a  suspicion  of  bronchopneumonia.  If  the 
nature  of  the  consolidation  has  remained  doubtful,  a  crisis  is  in  favor 
41 


642  DISEASES  OE    THE   RESPIRATORY    TRACT     • 

of  lobar  pneumonia,  tlu)U(i;h  it  appears,  on  rare  oceasions,  at  the  term- 
ination of  a  bronehopneumonia;  when  it  does  so  the  temperature  more 
often  shows  some  subsecjuent  fluetuations  than  the  subnormal  course 
seen  in  lobar  pneumonia.  After  the  attack  the  course  of  resolution  is 
often  a  useful  confirmatory  sign — in  lobar  pneumonia  the  lung  often 
clears  in  three  to  five  days;  in  bronchopneumonia  it  is  never  clear  by 
the  end  of  a  week,  and  it  generally  takes  ten  days  or  longer  before  all 
signs  are  gone. 

The  temperature  generally  fluctuates  in  bronchopneumonia;  in  lobar 
pneumonia  it  is  often  continuous,  moreover,  it  takes  a  generally  higher 
level  in  the  latter  disease,  a  temperature  of  104°  or  105°  F.  being  com- 
mon and  very  suggestive.  Hyperpyrexia,  if  this  occurs,  is  still  stronger 
evidence  on  the  side  of  lobar  pneumonia.  Cough  is  often  distressing 
in  bronchopneumonia;  it  is  generally  slighter  and  may  be  absent  in 
lobar  pneumonia.  Constipation  is  connnon  in  lobar  pneumonia,  but 
very  rarely  found  in  bronchopneumonia;  diarrhea  may  occur  with  either 
but  more  commonly  with  the  latter.  It  must  not  be  forgotten  that, 
though  the  victims  of  the  secondary  bronchopneumonias  are  generally 
poorly  nourished  and  sickly  children,  ])rimary  bronchopneumonia,  like 
lobar  pneumonia,  commonly  attacks  the  healthy. 

Child  and  Adult. — Lobar  pneumonia  in  the  child  is  closely  similar  to 
the  same  disease  in  the  adult,  but  certain  important  points  of  differ- 
ence need  emphasis.  At  the  onset  a  rigor  is  usual  in  the  adult,  rare 
in  the  child;  vomiting  is  usual  in  the  child,  rare  in  the  adult.  Cough 
is  a  more  important  feature  in  later  life  and  is  accompanied  by  the 
characteristic  rusty  sputum;  in  children  cough  is  often  slight  or  even 
absent,  and  there  is  no  expectoration. 

The  crisis  in  childhood  is  a  somewhat  less  important  feature  than  in 
adult  life;  it  occurs  in  a  smaller  proportion  of  cases,  the  fall  of  temper- 
ature is  often  less  rapid,  and  is  accompanied  by  less  sweating.  Herpes 
occurs  less  commonly  in  children. 

The  pulse-respiration  rate  is  disturbed  in  children  as  in  adults,  but 
as  a  diagnostic  sign  it  is  of  less  value,  since  in  childhood  it  is  readily 
disturbed  by  lung  conditions  other  than  pneumonia,  and  must  be 
considered  in  conjunction  with  other  signs. 

Apical  pneumonia  is  common  in  childhood  and  occurs  in  about  40 
per  cent,  of  all  cases;  in  adult  life  it  is  far  less  often  found.  Abortive 
cases  are  occasionally  met  with  in  the  adult,  but  they  are  probably  far 
commoner  in  childhood,  though  at  either  age  it  is  impossible  to  estimate 
in  what  percentage  they  occur. 

The  difference  in  the  mortalitij  of  the  disease  in  childhood  and  later 
life  will  be  described  in  the  next  paragraph. 

Prognosis. — This  depends  in  the  first  place  on  the  age  of  the  patient, 
for  the  mortality  is  very  much  higher  in  infancy  than  in  the  later  years 
of  childhood.  Among  196  cases  analyzed  by  myself  the  mortality  was 
25  per  cent,  in  the  first  year  of  life  and  15.4  per  cent,  below  the  age  of 
two  years.  Infants  die  from  mere  stress  of  the  disease  itself;  in  older 
children  recovery  takes  place  unless  some  f^tal  complication  supervenes. 


LOBAR  PNEUMONIA  643 

Of  complications,  the  infection  of  serous  cavities  by  the  pneumococcus 
is  the  most  serious ;  in  some  cases  many  serous  cavities  are  simultaneously 
affected  and  the  condition  was  probably  a  pneumococcus  pyemia  from 
the  beginning,  the  pneumonia  being  only  an  accidental  accompaniment. 
The  mortality  for  children  above  the  age  of  two  years  among  my  cases 
was  only  2.3  per  cent.;  that  for  children  of  all  ages  6.6  per  cent.  We 
thus  see  that  lobar  pneumonia  has  a  low  mortality  in  childhood  compared 
to  the  20  per  cent,  of  adult  life,  and  that  in  older  children  the  prognosis 
is  extremely  good.  It  is  largely  for  this  reason  that  a  diagnosis  from 
bronchopneumonia  is  important,  since  the  ultimate  outlook  is  so  different 
in  the  two  conditions. 

Treatment. — If  the  case  is  seen  at  the  very  onset  a  hot  bath  should  be 
immediately  given,  the  child  thereafter  being  placed  between  blankets, 
and  a  diaphoretic  hot  drink  containing  acetate  or  citrate  of  ammonia 
administered.  The  disease  will  occasionally  abort  at  the  very  beginning, 
though  it  is  very  doubtful  whether  the  remedies  employed  are  in  any 
way  responsible  for  this  happy  termination.  The  benefit  of  the  doubt 
should  be  given  on  the  side  of  active  treatment. 

When  the  disease  is  fully  established  it  is  well  to  remind  one's  self  at 
once  of  its  self-limited  course  and  the  non-existence  of  any  specific 
treatment.  Our  attention  must  be  given  to  watching  the  patient  through 
the  attack,  usually  short  and  of  favorable  termination  in  the  child,  and 
dealing  with  the  complications  as  they  arise. 

The  child  must  be  put  to  bed,  and  covered  with  light  clothing  in  a 
well-ventilated  room.  A  milk  diet  must  be  given  at  regular  intervals, 
and  in  moderate  quantities;  the  illness  promises  to  be  short  and  it  is 
wise  not  to  overtax  the  stomach.  Cold  water  should  be  freely  given  to 
relieve  thirst,  but  in  small  quantities  at  a  time.  The  bowels  are  generally 
confined  in  this  form  of  pneumonia  and  it  is  as  well  to  relieve  them  at 
the  beginning.  Calomel,  0.065  grn.  (1  gr.),with  0.13  to  0.2  gm.  (2  or  3  gr.) 
of  powdered  scammony  may  be  given  for  this  purpose.  Too  violent 
purgation  is  to  be  avoided.  In  a  case  of  normal  course  drug  treatment 
and  the  administration  of  stimulants  are  needless  and  even  harmful,  but 
the  skin  discomfort  may  be  somewhat  eased,  and  no  harm  done  by 
small  doses  of  the  citrate  or  acetate  of  ammonia,  1  c.c.  (15  minims)  of 
the  liquor  for  a  child  of  one  year,  at  three  or  four  hourly  intervals. 

The  skin  should  be  sponged  over  with  warm  water  two  or  three 
times  daily  without  disturbing  the  child  to  reach  inaccessible  parts, 
and  if  the  temperature  is  high  some  means  should  be  taken  to  keep  it 
within  reasonable  limits.  Children  are  generally  less  distressed  by  high 
temperature  than  are  adults,  but  it  must  be  remembered  that  its 
effect  on  the  tissues  is  deleterious  even  though  it  is  well  borne  by 
the  patient,  and  that  especially  where  the  remissions  are  but  slight. 
If  the  remissions  are  considerable  and  the  child  not  distressed  a  temper- 
ature of  104°  F.  may  be  left  alone,  beyond  the  daily  spongings;  if  the 
temperature  is  continuous  the  sponging  should  be  more  assiduously 
performed.  Cold  bathing  as  usually  done  distresses  the  child,  and  may 
not  be  followed  by  a  healthy  reaction. 


644  DISEASES  OF   THE  RESPIRATORY    TRACT 

Witli  the  higluT  temperatures,  whieh  are  not  at  all  uncommon  with 
pneumonia  in  youni:;  children,  the  fever  should  l)e  controlled  l)y  cold 
packing:;  or  by  "cradling"  or  "ice-cradling."  In  the  former  method  the 
child  is  wrapped  in  a  towel  wrung  out  of  cold  water  and  a  blanket  laid 
over.  The  pack  is  changed  at  intervals  until  the  temperature  is  sufficiently 
reduced.  "Cradling"  is  a  better  method,  as  it  involves  no  disturbance 
of  the  patient.  The  bed-clothes,  which  should  be  light,  are  raised  over 
a  wicker  or  metal  "cradle,"  which  crosses  the  patient  from  side  to  side 
like  a  wide  bridge.  The  "cradle"  is  open  at  the  end  for  the  air  to  enter, 
the  child's  body  Ix'ing  covered  with  a  night-dress  or  thin  lilanket.  In 
"  ice-cradling"  l)ags  of  ice  are  hung  along  the  top  of  the  cradle  at  intervals. 
The  child  may  remain  "cradled"  for  days,  or  as  long  as  the  temperature 
recjuires  it.  In  all  these  methods  it  is  of  the  utmost  importance  that  the 
feet  and  legs  be  well  clothed  and  kept  warm  with  hot-water  bottles. 
This  is  so  often  overlooked  that  physicians  and  nurses  must  be  reminded 
of  it  from  time  to  time.  Antipyretic  drugs  are  but  rarely  necessary  or 
advisable.  When  cold  is  used  to  reduce  fever  the  temperature  falls 
several  degrees  after  the  agent  is  removed,  so  it  is  well  to  stop  the  appli- 
cation when  102°  F.  or  thereabouts  is  registered. 

Nervous  symj)toms,  a.s  delirium  and  sleeplessness,  are  generally 
controlled  by  reducing  fever,  but  occasionally  other  meajis  are  needed 
in  addition.  For  either  small  doses  of  Dover's  powder  may  be  tried, 
and  if  occurring  late  in  the  illness  they  may  be  due  to  exhaustion  and 
be  removable  by  alcohol  and  stimulants. 

The  heart  is  less  often  a  cause  of  trouble  than  in  pneumonia  of  adults; 
nevertheless  its  condition  must  be  carefully  watched.  Failure  may  occur 
in  either  of  two  ways :  first,  the  whole  heart  may  be  poisoned  by  the 
fever  and  products  of  the  disease,  in  which  case  the  child  is  ])allid,  with 
cold  extremities,  rapid,  weak,  and  irregular  pulse,  and  perhaps  vomiting; 
or,  second,  the  disability  may  be  of  the  asphyxial  type,  involving  the 
right  chambers  mainly,  and  causing  cyanosis  and  increased  dyspnea, 
with  widening  of  the  cardiac  dulness  to  the  right  of  the  sternum.  For 
both  conditions  cardiac  stimulants  must  be  given,  and  for  the  latter, 
in  addition,  in  England  we  depend  on  bleeding  by  the  application  of 
leeches  over  the  chest  wall  or  liver.  In  this  latter  cUtss  of  cases  nitro- 
glycerin is  regarded  in  America  as  useful  in  relieving  engorgement  of 
the  right  heart. 

Oxygen  is  to  be  administered  in  both  these  classes  of  cases. 

The  best  stimulant  is  strychnine,  which  may  be  given  in  doses  of 
0.0003  gm.  (yfo  g^-)'  ^t  four  to  six  hourly  intervals  for  a  child  of  one 
year.  Alcohol  is  preferred  by  some  and  is  especially  useful  for  heart 
weakness  of  the  syncopal  type.  It  is  best  given  in  the  form  of  whiskey 
or  brandy,  of  which  \  to  1  ounce  may  be  given  daily  to  a  child  of  one 
year.  I'his  may  be  exceeded  for  short  periods  if  necessary,  and  it  is 
always  well  to  reserve  the  largest  proportion  of  the  daily  allowance 
for  those  times  (generally  the  small  hours  of  the  morning)  when  the 
temperature  and  vitality  are  lowest. 

If  brandy  or  whiskey  is  objected  to   rectified  spirit  may  be  tried  in 


LOBAR  PNEUMONIA  645 

half  the  dose,  the  taste  being  hardly  perceptible  if  given  in  milk.  Caffeine 
and  digitalis  are  recommended  by  many.  I  have  had  no  experience  of 
their  use.  Jacobi  mentions  camphor  and  musk,  and  it  is  reasonable  to 
believe  that  they  may  be  of  benefit. 

Pain  in  the  side  may  be  relieved  by  strapping,  if  well  borne,  or  by 
a  mustard  plaster,  or  light  poultice  of  mustard  and  linseed  (1  to  5  or  6). 
Opiates  may  be  given  if  necessary. 

Throughout  the  attack  a  watchful  eye  must  be  kept  for  complications, 
especially  those  more  treatable  ones,  otitis  media  and  pleural  effusion. 


CHAPTER   XXYI. 

PLEURISY— EMPYEMA— PNEUMOTHORAX. 

PLEURISY. 

Inflammation  of  tlie  pleura  loads  to  one  of  three  results,  either  drv 
pleurisy,  in  which  no  measural)le  quantity  of  fluid  is  formed,  or  sero- 
fibrinous pleurisy,  or  empyema.  The  first  is  <(enerally  an  accidental 
complication  of  some  pulmonary  inflammation,  either  a  pneumonia  or 
a  tuberculous  consolidation;  the  second  is  generally,  to  all  intents  and 
purposes,  a  primary  disease  and  is  commonly  caused  by  the  tuljerde 
bacillus,  though  it  may  accompany  croupous  pneumonia;  the  third  may 
be  primary,  but  is  often  secondary  to  a  lung  inflammation,  either  pneu- 
monia, in  which  case  the  pneumococcus  is  generally  the  cause,"  or  some 
septic  lesion,  as  an  infarct  or  abscess,  due  to  the  inroad  of  someone  or 
other  of  the  pyogenic  organisms. 

Dry  Pleurisy. — Dry  pleurisy  may  be  dismissed  in  a  few  words.  It 
accompanies  any  lung  inflammation  which  reaches  the  surface  and  is 
found  in  lobar  pneumonia,  in  bronchopneumonia  where  the  con- 
solidation is  considerable,  oyer  infarcts,  and  in  chronic  tuberculosis. 
The  surface  appears  dry  and  rough  and  generally  coyered  with  a  thin 
layer  of  fibrin,  and  the  condition  giyes  rise  to  the  friction  rub  so  fre- 
quently heard  oyer  consolidated  areas.  It  leads  to  permanent  adhesions 
between  the  pleural  surfaces  and,  judging  from  the  frecpiency  with 
which  these  are  found  in  the  postmortem-room,  this  and  the  following 
form  must  occur  with  considerable  frequency. 

Serofibrinous  Pleurisy.  Etiology. — It  may  occur  as  a  localized 
collection  of  serum  oyer  the  surface  of  the  solid  lung  in  croupous  pneu- 
monia, and  in  this  connection  is  described  under  the  heading  of  that 
disease. 

The  disease  to  which  the  name  pleurisy  is  usually  giyen  is  a  primary 
inflammation  of  the  pleura,  and  occurs  nearly  always  in  children  aboye 
the  age  of  two  years.  It  is  probably  of  tuberculous  nature  in  nearly  all 
cases,  though  the  tubercle  bacillus  cannot  always  be  demonstrated; 
it  is,  howeyer,  significant  that  the  more  perfect  the  methods  employed 
the  larger  is  the  proportion  in  which  this  organism  is  isolated  and  by 
a  recent  method,  in  which  the  congealed  .serum  was  liquefied  by  digestiye 
agents,  the  tubercle  bacillus  was  found  in  all  the  cases  examined. 
jVIoreoyer,  the  fluid  is  practically  always  sterile  on  culture  media  which, 
at  any  rate,  excludes  other  organisms.  The  majority  are  probably 
primary,  just  as  tuberculous  peritonitis  may  be  primary,  but  it  seems 
likely,  on  the  other  hand,  that  in  some  cases  the  process  spreads  from 
caseous  lymph  nodes  lying  beneath  the  pleura  between  the  pulmonary 
( 646 ) 


PLEURISY 


647 


lobes,  these  in  their  turn  having  been  infected  by  spread  from  that 
common  primary  focus,  the  lymph  node  or  nodes  beneath  the  bifurcation 
of  the  trachea.  It  is  a  significant  fact  that  deHcate  children  are  so  often 
attacked  with  serous  pleurisy,  and  that  so  commonly  a  long  history  of 
cough  and  wasting,  often  following  measles,  precedes  the  onset  of  the 
pleural  inflammation. 

Certain  influences,  such  as  cold,  which  tend  to  lower  resistance,  may 
be  the  factors  immediately  determining  the  onset,  and  among  these 
injury,  such  as  a  blow  on  the  chest,  must  be  included. 

Serofibrinous  pleurisy  is  occasionally  rheumatic  in  origin,  but  I  have 
never  seen  a  large  effusion  due  to  this  cause. 

Pathology. — The  fluid  is  clear,  greenish  yellow  in  color,  and  soon 
forms  a  translucent  clot  on  standing.  The  pleural  surface  is  covered 
with  a  layer  of  fibrin,  which  is  generally  thin,  and  most  marked  on  the 
pulmonary  pleura,  but  may  form  a  thick,  greenish  layer.  Where  thick, 
it  generally  shows  a  shaggy  surface,  but  where  thin  may  have  a  beautiful 
reticulated  appearance.  The  lung  is  partially  or  entirely  collapsed,  the 
pleura  looking  white  and  thickened  on  this  account;  it  is  tough  to  cut, 
flabby  and  airless,  and  the  cut  surface  is  of  a  dark  chocolate-brown  color 
crossed  by  the  obvious  double  white  lines  of  the  bronchial  tubes.  The 
neighboring  organs  are  variously  displaced  according  to  the  amount 
and  position  of  the  fluid. 

Symptomatology.  Onset. — The  onset  is  seldom  abrupt;  generally  the 
symptoms  develop  themselves  gradually  over  a  period  of  several  days. 
Vomiting  is  rare  as  an  initial  symptom;  chilliness  occurs  in  a  fair  pro- 
portion of  cases,  but  does  not  amount  to  a  rigor.  It  is  accompanied 
by  cough,  fever,  and  jyain  in  the  side.  Frontal  headache  is  complained 
of,  and  the  bowels  are  nearly  always  costive.  The  breathing  becomes 
difficult,  quick,  and  shallow,  as  more  and  more  fluid  is  effused;  the 
effusion  generally  forms  rapidly.  The  child  is  listless  and  quiet,  but  is 
often  not  sufficiently  ill  to  take  to  his  bed,  and  may  go  about  for  several 
days  before  the  importance  of  the  condition  is  recognized.  Indeed, 
the  onset  is  occasionally  so  insidious  that  dyspnea  caused  by  a  large 
effusion  is  the  first  thing  noticed. 

Very  commonly  a  history  of  cough  and  wasting  of  some  months' 
duration  preceding  the  immediate  onset  is  obtained,  as  already  men- 
tioned, and  I  have  observed  that  measles  is  a  very  common  antecedent. 

The  cough  is  sometimes  the  first  symptom  noticed  but  often  it  is 
delayed  for  a  day  or  two;  it  is  short,  dry,  and  hacking,  and  unaccom- 
panied by  expectoration ;  it  generally  causes  pain  in  the  side  or  accent- 
uates that  already  present.  The  jpain  is  of  early  appearance,  and  is 
situated  either  in  the  side  of  the  chest  or,  not  infrequently,  in  the  abdo- 
men, sometimes  simulating  that  of  appendicitis  or  some  other  abdominal 
disease,  and  on  one  occasion  I  have  seen  it  referred  to  the  region  of  the 
shoulder-joint  on  the  affected  side.  The  pain  is  generally  severe  and 
cutting  and  accompanies  inspiration,  especially  if  a  deep  breath  is 
taken;  movement  of  the  chest  on  the  affected  side  is  often  voluntarily 
limited  to  avoid  it.    At  the  beginning  the  pain  is  increased  by  pressure 


648 


DISEASES  OF   THE  RESPIRATORY   TRACT 


over  the  inflamed  area,  and  the  eliild  inclines  to  he  on  the  back  or  the 
opposite  side,  bnt  a,s  the  eifusion  forms  the  ]Kiin  <>;oes,  and  the  child 
hes  on  the  att'eeted  side  to  give  more  pUiy  to  the  heahhy  lung. 

The  breafhing  depends  on  the  local  conditions  present.  At  the 
beginning  it  is  (piiek  and  shallow,  owing  to  pain  caused  by  deep  inspi- 
ration; when  an  elbision  is  present,  if  small,  the  breathing  may  not  be 
appreciably  altered  from  the  normal,  but  when  large  the  respirations 


Vu;.  MO 


Pleurisy:  line  of  fluid  anteriorly. 


are  again  rapid  and  shallow,  the  alje  nasi  work,  and  the  pulse-respiration 
ratio  may  be  altered  so  as  almost  to  simulate  that  of  pneumonia. 

The  temperature  is  generally  high  during  the  acute  stage,  101°  or 
102°  F.  being  a  common  figure.  It  usually  remains  raised  for  four  days 
to  a  week  and  sometimes  longer,  with  considerable  fluctuations.  The 
skin  is  hot  and  often  dry  during  the  day,  with  profuse  sweating  in  the 
niirht  and  earlv  mornintj  hours. 

During  the  attack  the  child  loses  flesh,  is  weary  and  restless,  and 
constipation  often  demands  treatment.     The  tongue  is  furred,  the  face 


PLEURISY 


649 


pale,  with  often  a  slight  straw-yellow  tint  observable,  mostly  around  the 
eyes  and  mouth.  This  is  less  noticeable  in  cases  of  serous  effusion  than 
in  empyema,  where  the  rapidly  produced  anemia  heightens  the  effect. 
The  finger-tips  may  become  glazed  in  a  few  cases  where  the  fluid  has 
remainefl  unabsorbed  for  two  or  three  weeks,  but  any  definite  "clubbing' 
rarely  occurs  with  uncomplicated  serous  effusion. 

Position  of  Lesion. Serous  effusions  are  seldom  loculated,  but  may 
be  sometimes.  ^Yhen  they  occur  over  the  solid  lung  in  croupous  pneu- 
monia they  often  remain  localized  and  do  not  spread  around  the  chest. 


Fig. 141 


Pleurisy:  line  of  fluid  jKjsteriorly. 


Primary  effusions  may  be  loculated  at  the  commencement,  but  if  they 
increase  in  size  they  become  free  and  spread  around  the  base  of  the 
lung  so  that,  as  a  rule,  the  signs  of  fluid  are  found  both  in  front  and 
behind.  In  children  an  interesting  form  of  loculated  serous  effusion 
sometimes  occurs  and  may  readily  lead  to  a  false  diagnosis.  This  is 
an  effusion  appearing  in  the  front  of  the  chest  over  the  middle  lobe  on 
the  right  side,  e-iving  rise  to  signs  which  are  liable  to  be  mistaken  for 
cardiac  enlargement  or  pulmonary  collapse.  The  collection  may  be 
absorbed  without  further  spread,  but  generally  it  increases  in  size,  its 


650  DISEASES  OF   THE  RESPIRATORY   TRACT 

limitations  are  broken  down,  anil  the  fluid  spreads  around  the  chest 
in  the  ordiiiarv  manner. 

Commonly,  a  serous  effusion  is  found  at  the  base  of  one  or  other 
pleural  sac,  but  occasionally  it  may  be  double,  both  pleura?  being 
involved,  and  if  the  amount  of  fluid  poured  out  is  moderate,  the  ease 
mav  rim  a.s  favorable  a  course  a.s  when  the  efl"usion  is  single.  Neverthe- 
less, in  such  cases  the  probability  of  some  primary  tuberculous  lesion 
elsewhere  being  the  cause  of  the  trouble  nn;st  l)e  taken  into  consideration. 

The  quantity  of  fluid  varies  between  an  ounce  or  two  and  as  much 
as  one  and  a  half  pints  in  a  child  of  three  and  one-half  to  four  years  of 
age,  the  l;irg(>r  efl'usions  ])eing  distinctly  less  common. 

Physical  Signs.  lu.spccfioii. — On  examining  the  chest  it  will  generally 
be  observed  that  movement  is  deficient  on  one  side,  though  with  efl'usions 
of  moderate  size  in  children  this  may  be  quite  unnoticeable;  with  large 
effusions  the  loss  of  mobilitv  is  always  obvious.  Some  enlargement  of 
the  side  due  to  release  of  the  elastic  expansion  of  the  thorax  may  be 
found  on  measurement,  but  can  hardly  be  seen.  Tlie  displacement  of 
the  heart's  apex  may  be  observed  on  inspection  but  is  best  determined 
by  palpation. 

VaJpation  and  Percussion. — With  a  right-sided  effusion  the  heart  and 
mediastinum  are  drawn  to  the  left  by  release  of  the  elastic  tension  of 
the  healthy  lung,  both  the  apex  beat  and  the  left  area  of  cardiac  dulness 
being  found  outside  their  normal  position.  In  cases  of  large  effusion 
the  left  limit  may  be  the  anterior  axillary  line.  When  the  effusion  is 
on  the  left  side  the  heart  and  mediastinum  move  to  the  right,  the  point 
of  maximum  impulse  is  often  in  the  epigastrium  or  even  in  the  fourth 
space  to  the  right  of  the  sternum,  and  the  cardiac  dulness  may  reach 
to  the  right  nipple  line.  The  liver  or  spleen  are  displaced  downward 
with  large  effusions. 

Vocal  vibration  cannot  l)e  obtained  in  children  owing  to  the  treble 
(piality  of  the  voice,  and  thus  a  valuable  sign  of  fluid  is  lost.  A  fluid 
wave  may,  however,  be  obtained  in  some  cases  by  placing  a  hand  on 
the  back  of  the  chest  while  an  assistant  percusses  firmly  over  the  front. 

On  percussion  over  the  affected  area  a  dull,  wooden  note  is  elicited 
and  a  sensation  of  great  resistance  is  imparted  to  the  fingers;  if  a  con- 
siderable amount  of  fluid  is  present,  the  quality  of  this  resistance  is 
almost  pathognomonic  of  its  cause,  only  one  other  condition,  pul- 
monary fibrosis,  giving  a  comparable  sensation.  The  dulness  may 
extend  to  the  apex  in  large  efl'usions,  but  is  always  most  absolute  at  the 
base.  When  the  effusion  is  large  it  will  be  found  to  cross  the  middle  line 
of  the  chest  above  the  heart  in  front,  giving  dulness  to  the  opposite 
border  of  the  sternum  or  even  beyond  this.  In  smaller  effusions  the 
upper  limit  is  not  sharply  defined,  but  an  area  of  impairment  exists 
above  it.  Often  the  hmg  above  the  effusion  gives  a  high-pitched,  boxy, 
or  even  tympanitic  note  to  percussion. 

Very  commonly  the  signs  of  a  pleural  effusion  reach  to  the  scapular 
angle  or  just  above  this  behind,  to  an  equal  height  in  the  axilla,  and 
often  somewhat  lower  in  front.     The  upper  limit  changes  somewhat 


PLEURISY 


651 


with  changes  of  attitude.  On  the  left  side  it  must  be  remembered  that 
the  pleural  sac  extends  some  inches  below  the  base  of  the  lung  in  the 
front  of  the  chest,  and  that,  consequently,  a  free  effusion  reaches  down- 
ward nearly  to  the  costal  margin,  covering  the  so-called  "Traul>e's 
space,"  where  stomach  resonance  is  usually  obtained.  Here  the  fluid 
forms  but  a  thin  layer,  and  the  stomach  resonance  tends  to  mask  its 
presence,  which  is  often  best  recognized  by  the  sense  of  increased  resist- 
ance to  light  percussion. 

Auscultation. — Over  the  dull  area  the  breath  sounds  are  distant, 
especially  at  the  base,  where  with  large  effusions  they  may  be  inaudible. 
The  quality  of  the  breath  sounds  varies  in  different  cases;  in  older 
children  they  are  often  vesicular,  as  in  the  adult,  but  often,  especially 
in  early  years,  the  breath  sounds  are  bronchial  or  sometimes  broncho- 
vesicular.  This  may  cause  exceptional  difficulty  in  diagnosis  between 
effusions  and  solid  lung  in  infancy.  The  bronchial  quality  of  the 
breath  sound  depends,  no  doubt,  on  the  condition  of  the  lung  beneath, 
though  it  is  difficult  to  understand  why  the  same  condition  should  not 
be  found  in  adults  as  in  children  in  this  respect.  Perhaps  the  readiness 
with  which  pulmonary  collapse  occurs  in  childhood,  together  with  the 
relatively  large  size  of  the  bronchial  tubes,  may  afford  the  explanation; 
in  empyema  it  depends  in  many  cases  on  inflammatory  consolidation 
of  the  underlying  lung. 

Pleural  friction  may  be  audible  at  the  upper  limit  of  the  effusion  or 
will  appear  when  absorption  takes  place.  In  childhood  it  is  very  fine 
in  quality  and  difficult  to  distinguish  from  intrapulmonary  rales;  it 
generally  accompanies  both  inspiration  and  expiration.  In  cases  where 
it  is  loud  and  of  sharp,  resonant  quality,  the  sound  may  often  be  con- 
ducted to  the  opposite  side  of  the  chest,  giving  rise  to  errors  of  diagnosis 
unless  the  possibility  of  this  is  recognized.  The  fact  that  the  quality 
of  the  sounds  on  the  two  sides  is  identical,  the  one  being  but  a  faint 
replica  of  the  other,  wnll  generally  point  to  the  true  condition  present. 
In  some  cases  both  sounds  may  be  simultaneously  arrested  by  turning 
the  patient  on  to  the  affected  side  and  thus  limiting  the  movements  of 
the  rubbing  surfaces. 

The  vocal  resonance  is  diminished  over  the  effusion.  As  in  adults, 
it  often  has  a  peculiar  nasal  quality  which  may  be  very  marked,  giving 
a  bleating  tone  to  the  voice  (egophony).  This  is  usually  found  in  cases 
where  the  breath  sounds  are  bronchial  and  is  most  marked  at  one  spot, 
generally  the  scapular  angle.  Above  the  level  of  the  effusion  the  vocal 
resonance  may  be  somewhat  increased. 

Termination. — After  remaining  in  statu  quo  for  a  variable  period, 
often  but  three  or  four  days  after  it  has  attained  its  maximum,  the 
effusion  begins  to  be  absorbed,  and  is  generally  gone  or  nearly  gone  by 
the  end  of  the  second  week,  though  it  may  remain  longer.  The  rest  for 
the  inflamed  surface  afforded  by  the  fluid  covering  has  allowed  healing 
to  take  place,  and  the  lesion  is'  cured.  Slight  impairment  at  the  base 
and  weak  air  entry,  due  to  a  sodden  and  partly  collapsed  condition  of 
lung,  remain  for  a  short  time  after  the  fluid  has  disappeared. 


652  DISEASES  OF    THE   RESPIRATORY    TRACT 

Diagnosis. — The  diagnosis  of  serous  effusion  seldom  presents  the  same 
difficulties  Jis  does  that  of  empyema.  The  subjects  are  generally  older, 
and  the  Huid  is  nearly  always  free  in  the  j)lcural  cavity.  It  is  by  loculated 
effusions,  so  often  found  in  empyema,  that  the  signs  of  pneumonia  may 
he  closely  simulated,  hence  the  diagnosis  between  these  conditions  will 
be  considered  when  empyema  is  dealt  with.  The  diagnosis  from 
])ulm()narv  collapse  has  been  already  consid(>rcd  under  that  heading. 

Prognosis. — Serofibrinous  efi'usion  is  never  fatal  on  its  own  accoimt, 
with  the  exception  of  certain  rare  cases  of  sudden  death  where  the  dis- 
placement of  neighboring  organs  has  been  considerable.  As  a  rule, 
the  condition  clears  up,  and  nothing  further  may  happen,  but  it  is  well 
to  remember  that  double  effusion  often  implies  a  pre-existing  tuberculous 
focus,  and  that  even  primary  cases  are  generally  tuberculous  in  nature, 
and  mav  be  followed  by  pulmonary  tuberculosis. 

Treatment. — At  the  beginning  the  patient  should  be  put  to  bed,  the 
bowels  opened  with  a  calomel  purge  and  their  subse(|uent  regular 
action  attended  to.  The  diet  should  be  light,  a  diaphoretic  mixture 
may  be  given,  and  the  pleural  pain  treated  by  a  firm  bandage  or,  if 
required,  by  a  hypodermic  injection  of  morphine,  0.003  to  0.00.5  gm. 
(_i^  to  y^^  gr  )  for  a  child  of  four  to  five  years.  Leeches  or  cupping  will 
often  afford  relief.  In  the  majority  of  cases  the  temperature  falls  within 
a  week,  and  the  fluid  begins  to  be  absorbed  after  about  ten  days,  often 
disappearing  by  the  twelfth  or  fourteenth  day.  In  cases  of  effusion  so 
large  that  the  whole  pleural  cavity  appears  filled,  \\ith  considerable 
displacement  of  the  surrounding  viscera,  it  is  well  to  aspirate  a  part 
of  the  effusion  at  once.  When  the  collection  is  smaller  it  may  be  left 
two  and  a  half  to  three  weeks,  and  iodides  in  the  form  of  potassium 
iodide,  0..3  gm.  (.'S  gr.)  for  a  child  of  four  or  five  years,  may  be  admin- 
istered the  while  in  a  diuretic  mixture  containing  0.13  to  0.2  gm.  (2  or  3 
gr.)  of  potassium  nitrate  with  infusum  scoparii,  8  c.c.  (2  dr.),  A  dry 
but  copious  diet  siiould  be  given,  the  bowels  kept  freely  moved,  and 
the  chest  wall  at  the  same  time  stimulated  with  local  applications  of 
iodine  paint. 

If  at  the  end  of  this  time  there  is  no  change,  the  fluid  should  be 
aspirated,  as  the  lung  is  apt  to  expand  imperfectly  if  left  too  long  in  a 
collapsed  condition. 

For  aspiration  the  child  sits  forward  with  the  arms  extended  over  a 
large  pillow  on  his  knees,  the  chest  wall  is  carefully  prepared  as  for 
other  surgical  procedures,  and  the  needle  to  be  used  is  boiled.  A  spot 
at  the  base  of  the  thorax  behind  is  chosen ,  w'here  the  dulness  is  most 
complete  and  the  intercostal  spaces  accessible,  the  liver  being  avoided 
on  the  right  side.  The  needle  is  entered  swiftly  and  steadily  close  to 
the  upper  border  of  a  rib,  care  being  taken  to  avoid  any  stabbing  move- 
ment, which  gives  so  unpleasant  a  sensation  to  the  patient.  The  needle 
is  in  connection  either  with  an  asy)irating  bottle  exhausted  by  an  air 
pump,  or  w^ith  a  letigth  of  tubing  for  sij)h<)nage.  Either  acts  well,  though 
the  former  is  more  efficient  in  case  the  fluid  cannot  be  got  to  flow  readily. 
The  whole  of  the  fluid  may  be  aspirated,  though  there  is  no  advantage 


EMPYEMA 


653 


in  removing  it  completely,  since  any  that  remains  behind  is  likely  to 
be  rapidly  absorbed.  Accidents  during  aspiration  are  very  rare  indeed. 
If  fresh  blood  comes  with  the  fluid,  it  is  well  to  stop  the  aspiration  at 
once.  Edema  of  the  lungs  occurs  in  rare  cases,  but  is  almost  never 
fatal.  Cases  of  sudden  death  during  aspiration  have  been  recorded, 
but  they  are  very  rare  and  have  generally  been  attributable  to  the  too 
rapid  removal  of  a  large  effusion.  The  re-accumulation  of  an  effusion 
is  not  of  common  occurrence  in  childhood. 

Having  cured  the  effusion,  the  general  condition  of  the  patient  must 
be  brought  up  to  a  high  standard  on  the  suspicion  of  underlying  tuber- 
culosis. Change  of  air  to  a  dry,  bracing  climate  is  desirable,  as  also 
good,  but  judicious  feeding,  and  some  preparation  of  cod-liver  oil  with 
iodide  or  phosphate  of  iron.  The  standard  of  good  health  thus  attained 
must  not  be  allowed  to  wane. 

EMPYEMA. 

A  true  serous  effusion  rarely  becomes  purulent;  the  cause  of  the  two 
conditions  is  different,  on  the  one  hand  the  tubercle  bacillus,  on  the 
other  hand,  in  children,  the  pneumococcus  in  the  majority  of  cases. 
It  is  true  that  in  early  stages  of  pneumococcic  inflammation  the  fluid 
may  appear  to  be  serous  and  will  clot,  but  it  has  nearly  always  some 
turbidity  due  to  pus  cells,  and  grows  the  pneumococcus  on  an  agar 
medium  where  the  culture  from  the  true  serous  effusion  remains  sterile. 
Such  an  effusion  complicating  a  pneumonia  may  occasionally  be 
absorbed,  but  when  the  pneumococcus  is  found  the  formation  of  a 
purulent  collection  may  be  expected. 

Etiology. — Empyema  is  either  primary  or  secondary,  though  the  pro- 
portion of  cases  assignable  to  either  of  these  divisions  is  impossible  to 
determine.  The  primary  cases  form  the  smaller  number  and  are 
probably  always  pneumococcic.  The  disease  starts  in  the  pleura,  and 
the  onset  is  either  rapid,  when  pneumonia  is  simulated,  or  gradual  like 
the  onset  of  serofibrinous  pleurisy.  The  secondary  cases  are  generally 
dependent  on  lung  diseases.  The  majority  of  them  follow  pneumonia, 
generally  croupous,  but  sometimes  bronchopneumonia,  and  the  onset 
is  that  of  one  of  these  diseases,  the  pleurisy  developing  during  its  course. 
In  some  cases  the  lung  and  the  pleura  are  attacked  simultaneously,  in 
others  there  is  a  variable  interval,  but  usually  the  empyema  follows 
very  closely  on  the  lung  consolidation.  Some  cases,  few  in  number, 
develop  in  the  course  of  a  pulmonary  tuberculosis ;  some  complicate 
fibrosis  of  the  lung.  In  either  case  the  pneumococcus  is  found  in  the 
pus,  but  in  a  few  of  the  tuberculous  cases  the  tubercle  bacillus  is  also 
present.  The  remainder  of  the  secondary  cases  are  septic  in  origin, 
and  foflow  such  diseases  as  osteomyelitis,  pyemia,  appendicitis,  tonsillitis, 
retropharyngeal  abscess,  or  the  infective  fevers,  when  the  organism 
associated  with  the  original  disease  will  generally  be  found  in  the 
pleural  pus.  Septic  infarction  of  the  lung  is  the  mode  by  which  the 
pleural  cavity  becomes  infected  in  some  of  these  cases. 


654  DISEASES  OF   THE  RESPIRATORY    TRACT 

Empyema  is  an  uncommon  diseavSe  among  the  well-to-do. 

Pathology.  Bacteriology. — This  differs  considerably  in  children  and 
adults  owintf  to  the  important  role  played  by  the  pneumococeus  in  the 
infective  inflanunation  of  childhood.  Among  77  causes  in  which  the 
pus  was  examined  by  myself  the  following  organisms  were  found: 

Pneumococeus  (alone) 66  or  85.7  per  cent. 

Streptococcus  (alone) 3  "    4.0       " 

Staphylococcus  aureus  (alone) 3 "    4.0       " 

Pneumococeus  and  streptococcus 3  "    4.0       " 

Pneumococeus,  staphylococcus,  and  a  bacillus        .       .       .      2  "    2.5       " 

77  "100.2 

If  these  results  are  compared  with  the  conditions  found  in  the  adult, 
as  given  by  Netter,  the  contrast  is  striking. 

Pneumococeus 17.2  per  cent. 

Streptococcus 53.0       " 

Staphylococcus 1.2       " 

Pneumococeus  and  streptococcus '    .       .       .25       '• 

Tubercle  bacillus 25.0        " 

Thus  it  appears  that  in  the  adult  the  bulk  of  the  cases  are  strepto- 
coccic, and  next  to  this  comes  the  tubercle  bacillus  as  a  cause,  the 
condition  being  often  secondary  to  phthisis.  In  children  the  tubercle 
bacillus  is  an  uncommon  cause,  and  when  found  is  generally  associated 
with  the  pneumococeus ;  in  many  empyemas  associated  with  tuberculosis 
the  pneumococeus  only  is  present. 

Morbid  Anatomy. — On  opening  the  thorax  the  heart  and  mediastinum 
are  found  displaced  to  one  or  other  side  if  the  effusion  is  large  and 
untreated.  Not  uncommonly  there  is  some  mediastinal  cellulitis,  and 
the  sternum  is  found  to  be  more  closely  bound  to  the  underlying  struc- 
tures than  normally.  On  the  affected  side  adhesion  of  the  pleural  surface 
is  generally  the  first  thing  noticed,  and,  on  separating  these,  the  cavity 
of  the  empyema  is  exposed  to  view.  The  pus  is  generally  green  in 
color,  and  the  pleural  surfaces  are  coated  with  a  layer  of  thick,  green 
fibrino-pus.  The  pus  may  be  thin  and  watery,  or  it  may  be  thick  and 
oily  in  consistence,  or  there  may  exist  only  layers  of  firm,  green  fibrin. 
When  the  last  condition  is  present  the  cause  is  generally  the  pneumo- 
coceus, but  not  invariably;  now  and  then  this  thick,  viscid  secretion  is 
found  in  streptococcic  and  staphylococcic  infections.  Thin,  watery  pus 
separating  into  layers  is  suggestive  of  septic  infection,  but  it  sometimes 
occurs  also  where  the  pneumococeus  only  is  present,  and  when  found 
after  death  generally  indicates  a  recent  infection.  Had  the  patient 
lived  longer  the  pus  would  probably  have  become  thicker. 

The  empyema  cavity  is  generally  bound  by  adhesions  at  certain 
points,  even  where  not  definitely  localized.  It  may  be  found  in  any 
part  of  the  chest,  generally  at  the  base  and  behind,  and  may  be  double; 
occasionally  multiple  pleural  abscesses  are  found.  Such  cases  are 
generally  fatal,  and  constitute  rather  a  pathological  curiosity  than  a 
clinical  type. 

The  Lung. — Pulmonary  consolidation  is  so  common  an  accom- 
paniment of  empyema  that  some  amount  of  this  is  nearly  always  to  be 


EMPYEMA 


655 


found  after  death.  Lobar  pneumonia  is  a  common  cause  of  empyema, 
but  is  not  often  present  at  the  autopsy,  having  generally  cleared  up 
before  the  fatal  termination.  Most  commonly  bronchopneumonia  is 
found,  either  on  the  affected  side  or  sometimes  on  both;  it  is  generally 
a  complication,  and  one  that  leads  in  many  cases  to  death.  It  is  often 
extensive,  and  may  cause  consolidation  of  the  whole  or  the  greater  part 
of  a  lung;  it  is  present  in  about  one-half  of  the  fatal  cases.  In  a  per- 
centage of  cases  no  lung  consolidation  is  found  after  death,  the  pul- 
monary tissue  beneath  the  empyema  being  collapsed,  or  partly  collapsed, 
and  often  engorged  or  edematous.  In  cases  of  double  empyema  there 
may  be  bronchopneumonia  on  one  side,  and  collapse  on  the  other,  and 
yet  the  signs  may  be  similar  on  the  two  sides  namely,  those  of  con- 
solidation. On  the  other  hand,  where  the  lung  is  collapsed  beneath 
an  empyema,  the  signs  are  often  those  associated  with  the  presence  of 
fluid  in  the  adult,  or  the  breath  sounds  may  be  harsh,  but  not  distinctly 
bronchial. 

In  a  small  percentage  of  fatal  cases  of  empyema  tuberculosis  of  the 
lungs  is  found,  and  this  is  either  of  older  date  than  the  pleural  inflam- 
mation, or,  more  commonly,  is  of  subsequent  development.  In  staphylo- 
coccal empyemata,  and  those  due  to  other  septic  organisms,  pulmonary 
infarcts  or  abscesses  are  not  uncommonly  found,  these  having  led  to 
secondary  infection  of  the  pleura. 

Symptomatology. — The  onset  is  sometimes  rapid,  sometimes  gradual, 
though  more  commonly  the  former.  Among  cases  of  rapid  onset  a 
certain  ninnber  start  with  lobar  pneumonia,  but  it  is  very  difficult  to 
decide  what  proportion.  A  sudden  onset  does  not  necessarily  point  to 
pneumonia,  for  a  primary  empyema  may  undoubtedly  begin  abruptly; 
moreover,  the  crisis  which  occurs  in  many  of  these  cases  merely  argues 
a  self-limited  blood  infection,  it  is  no  indication  of  the  presence  of  a 
local  lung  inflammation.  In  some  cases,  no  doubt,  the  pneumonia 
and  pleural  inflammation  start  simultaneously. 

In  cases  of  gradual  onset  the  symptoms  are  similar  to  those  seen  in 
serofibrinous  pleurisy.  There  is  usually  a  dry,  hacking  cough  during 
some  weeks,  and  the'child  is  listless,  loses  the  power  of  walking  if  lately 
acquired,  wastes  somewhat,  and  may  sweat  profusely  at  night.  At  the 
end  of  this  time  the  breathing  becomes  short  owing  to  the  presence  of 
effusion,  and  the  signs  of  such  are  discovered  in  the  chest. 

When  the  onset  is  rapid  it  may  begin  with  the  symptoms  of  pneu- 
monia (either  lobar  or  primary  bronchopneumonia),  vomiting,  fever, 
and  short  breath,  the  cough  developing  somewhat  later,  and  not  form- 
ing a  noticeable  feature.  In  acute  cases,  where  the  pleural  inflammation 
is  presumably  primary,  the  onset  is  generally  with  cough  (often  a  more 
prominent  feature  than  in  pneumonia),  together  mth  fever  and  pam 
in  the  side,  which  may  in  some  cases  be  so  severe  as  to  cause  screammg. 
The  dyspnea  is  not  such  a  marked  feature  as  with  pneumonia,  and  may 
not  be' noticeable  unless  a  large  effusion  is  present.  The  child  is  restless 
at  night,  loses  appetite,  is  costive,  and  rapidly  wastes,  and  becomes 
intensely  anemic  if  the  disease  remains  untreated. 


656  DISEASES  OF   THE  RESPIRATORY   TRACT 

The  courjU  is  dry,  hiukiiif,',  and  ineffectual,  aiul  unaccompanied  by 
any  expectoration.  It  often  causes  pain  or  increases  that  already 
present.  The  pain  is  usually  in  the  side  of  the  chest,  but  it  may  be 
referred  to  the  abdomen,  or  to  the  cardiac  area  when  on  the  left  side. 
It  is  sharp  antl  stabbin*,'  in  character,  and  often  j)ro(luces  an  expression 
of  great  distress,  the  child  crying  out  or  screaming  at  intervals.  Pains 
all  over  the  body  are  sometimes  complained  of  at  the  onset. 

Dyspnea. — When  the  condition  begins  with  pneumonia  the  respi- 
rations take  the  type  seen  in  that  disease,  the  pulse-respiration  ratio 
being  generally  much  disturbed;  after  the  crisis,  if  such  occurs,  the 
respirations  may  fall  to  nornud  if  the  amount  of  effusion  is  small.  In 
cases  of  primary  pleural  inflammation,  whether  of  sudden  or  gradual 
on.'?et,  the  amount  of  respiratory  disturl)ance  depends  mainly  on  the 
quantity  of  fluid  poured  out.  When  the  effusion  is  small,  there  is  little 
disturbance;  when  the  effusion  is  large  tlu^  respirations  may  be  rapid, 
the  disturbance  of  the  pulse-respiration  ratio  reaching  3  to  1,  rarely 
more. 

Fever. — The  temperature  may  l)e  like  that  of  pneumonia  at  the 
onset  and  there  may  be  a  crisis,  either  delayed  or  at  the  normal  time, 
after  which  the  temperature  makes  slight  rises  until  the  empyema  is 
treated.  It  is  surprising  how  slight  an  increase  of  temperature  often 
accompanies  the  presence  of  an  empyema.  At  its  onset  there  is  usually 
a  high  temperature,  often  with  marked  fluctuations,  but  when  once 
estal)lished  scj^tic  absorption  seems  to  be  slight  in  many  cases  and  the 
temperature  often  remains  between  99°  or  100°  F,  at  night,  and  normal 
or  somewhat  subnormal  in  the  morning,  the  fluctuations  being  often 
but  1°  or  1\°.  It  is  important  to  recognize  the  fact  that  a  low 
temperature  is  not  incompatible  with  the  presence  of  an  empyema.  In 
many  cases  a  temperature  of  101°  F.  with  somewhat  large  fluctuations 
precedes  operation,  and  a  drop  to  normal  or  subnormal  follows  it  with 
no  subsetjuent  rise.  Occasionally  the  temperature  is  low  before  the 
operation  and  becomes  high  and  swinging  for  several  days  after  it, 
the  disturbance  having  led  to  greater  septic  absorption,  especially  in 
cases  where  drainage  is  imperfect.  Taking  it  altogether  the  temperature 
in  empyema  is  very  variable  and  erratic,  and  not  in  any  way  distinctive 
of  the  condition  causing  it.  As  an  indication  of  septic  absorption  it  is, 
however,  of  value,  and  will  draw  attention  to  deficiency  of  drainage 
during  treatment. 

Skin. — Night-sweating  may  occur  in  empyema,  though  the  skin  is 
harsh  and  dry  throughout  the  day.  Where  a  patient  with  lobar  pneu- 
monia sweats  profusely  all  is  not  normal,  and  empyema  may  cause  this 
in  some  cases  where  the  two  diseases  are  associated. 

In  pleurisy  of  long  duration  a  peculiar  straw-yellow  tinting  of  the 
skin  is  to  be. observed  in  the  pale  regions  of  the' face,  round  the  eyes 
and  mouth  especially.  In  cases  of  empyema  this  is  much  more  marked 
and  may  be  seen  on  the  body  as  well.  It  is  associated,  in  empvema, 
with  intense  anemia  and  the  peculiarly  flabby  and  wasted  muscles 
which  are  found  when  the  condition  has  remained  untreated  for  some 


EMPYEMA  657 

weeks.  This  yellow,  anemic  skin  is  valuable  in  diagnosis,  though  a 
somewhat  similar  appearance  in  children  is  noted  with  purulent  affec- 
tions elsewhere,  as  in  infective  meningitis  or  pericarditis.  Clubbing  of 
the  finger-tips  occurs  in  a  large  proportion  of  cases  and  may  be  of 
rapid  development. 

Physical  Signs. — The  signs  are  those  of  fluid  in  the  chest  and  are 
consequently  similar  to  those  described  under  the  heading  of  sero- 
fibrinous pleurisy.  Empyema,  however,  is  more  common  in  young 
children  and  more  often  associated  with  lung  consolidation  of  an 
inflammatory  nature,  and,  as  a  consequence,  those  signs — bronchial 
breathing  and  sometimes  bronchophony — which  may  simulate  a  simple 
pneumonia  are  commonly  present,  whereas,  in  the  serous  pleurisy  of 
older  children  the  signs  are  often  similar  to  those  of  effusion  in  the 
adult.  Moreover,  loculation  of  the  effusion  more  often  occurs  with 
empyema,  so  that  the  signs  may  be  found  only  over  a  limited  area  of 
the  chest,  generally  behind,  giving  a  still  closer  resemblance  to  pneu- 
monic consolidation.  In  cases  where  the  fluid  is  free  it  tends  to  gravitate 
to  the  lowest  parts  of  the  pleura,  and,  not  uncommonly,  a  whole  side  is 
found  dull  to  percussion,  the  signs  at  the  upper  part  being  due  to  solid 
lung,  which  gives  intense  tubular  breath  sounds  and  bronchophony,  and 
the  base  being  occupied  by  an  empyema,  the  breath  sounds  becoming 
feebler  as  one  descends  the  chest  wall,  though  retaining  their  bronchial 
character  wherever  audible.  In  effusions  of  no  great  size  the  signs  are 
often  widely  distributed,  a  thin  layer  of  pus  stretching  up  between  the 
pleural  surfaces. 

"When  only  a  thick  layer  of  fibrin  is  present,  a  condition  which  lies 
on  the  borderland  between  empyema  and  serofibrinous  pleurisy,  the 
signs  may  be  but  slight,  but  generally  there  are  dulness,  feebleness  of 
breath  sounds,  and  sometimes  a  "glutinous"  pleural  friction  sound. 
They  depend  in  most  part  on  the  condition  of  the  lung  beneath,  which 
may  be  that  of  consolidation,  or  of  partial  collapse. 

Apical  empyema  is  sometimes  met  with,  but  is  rare,  and  is  more  often 
diagnosed  than  found. 

Among  81  cases  of  empyema  collected  by  Mr.  P.  S.  Blaker  at  the 
East  London  Children's  Hospital,  42  occurred  at  the  left  base  and  30  at 
the  right  base;  9  were  double.  From  another  source  more  cases  were 
recorded  on  the  right  side  than  on  the  left,  from  which  it  appears  probable 
that  the  disease  shows  no  obvious  partiality  for  one  side  above  the 
other.  It  will  be  remembered  that  in  croupous  pneumonia  which  so 
often  precedes  this  disease  the  right  and  left  lungs  are  affected  in  a 
nearly  equal  number  of  cases. 

Rare  forms  of  empyema  are  interlobar  and  diaphragmatic  collections. 
Thick  layers  of  lymph  are,  however,  not  uncommonly  found  in  these 
situations  with  empyemata  of  wider  extent. 

Complications. — Uncomplicated    empyema,    unless    in    \er\    young 

infants,  is  seldom  found  in  the  autopsy-room.     The  disease  generally 

kills  through  its  complications  and  these  are  all  of  a  serious  nature. 

In  fatal  cases  caused  by  the  pneumococcus  it  often  happens  that  many 

42 


658  DISEASES  OF   THE  RKSPIRATORY   TRACT 

lesions  arc  associated,  especially  multiple  infection  of  serous  cavities 
(pericardium,  ])leura,  and  peritoneum),  and  often  in  such  cases  no  one 
affection  can  he  considered  primary,  the  disease  heing  prohably  a  blood 
infection  from  the  start,  a  pneumococcic  pyemia. 

Bronchopncumoiiia  is  perhaps  the  commonest  complication  and  often 
leads  to  death.  Doubtless,  cases  of  empyema  are  sometimes  secondary 
to  bronchopneumonia,  but  I  am  inclined  to  believe,  myself,  that  more 
often  it  is  the  bronchopneumonia  which  is  subsccjuent.  It  generally 
affects  the  partially  collapsed  lung  beneath  the  empyema  and  often 
leads  to  extensive  consolidation.  The  opposite  lung  also  is  affected 
in  many  cases. 

Pundent  pericarditis  is  found  in  a  large  number  of  fatal  cases,  both 
it  and  the  empyema  being  often  secondary  to  pneumonia.  It  h;is  been 
already  described  under  the  heading  of  lobar  pneumonia  (p.  G40). 

Pundent  meningitis  is  an  occasional  and  fatal  complication.  It  is 
often  present  in  association  with  other  infective  lesions,  especially 
suppurative  pericarditis.  Layers  of  greenish  fibrin  are  found  covering 
the  vertex  and  extending  in  some  cases  over  the  whole  surface  of  the 
brain,  'i'he  symptoms  are  often  obscure  in  young  children,  and  if 
pneumonia  is  also  present  they  may  be  ascribed  to  the  cerebral  symp- 
toms of  this  disease.  Convulsions  are  the  most  marked  symptom,  but 
if  the  base  is  also  involved  paresis  of  cranial  nerves  may  arise.  Occa- 
sionally an  unusually  slow  pulse  rouses  suspicion  when  no  other  symp- 
toms are  present. 

Pundent  Peritonitis, — A  suppurative  peritonitis  is  found  in  some 
fatal  cases  of  empyema  in  children,  most  often  so  in  cases  of  widespread 
infection  to  which  the  name  of  pyemia  might  be  given.  The  symptoms 
pointing  to  the  abdomen  may  be  so  slight  as  to  be  overlooked  among 
those  implicating  other  organs,  but,  when  sought  for,  abdominal  dis- 
tention and  the  ordinary  signs  of  peritonitis  may  generally  be  found. 

Cellulitis. — Not  uncommonly  there  is  some  inflammation  of  the 
cellular  tissue  of  the  mediastinum.  This  may  reach  such  a  grade  that 
the  heart  and  pericardium  are  surrounded  by  a  layer  of  pus,  which  may 
spread  back  over  the  vertebrae  and  round  the  chest  wall  between  the 
parietal  pleura  and  the  ribs.  In  some  cases  the  mediastinum  is  un- 
affected, but  there  is  a  layer  of  pus  spread  out  over  a  wide  area  of  the 
chest  wall  between  ribs  and  pleura,  generally  stretching  forward  from 
the  bodies  of  the  vertebra*.  I  have  observed  such  a  cellulitis  of  the 
chest  wall  without  empyema  as  a  complication  of  bronchopneumonia. 

Tuberculosis. — Empyema  sometimes  occurs  as  a  complication  of 
chronic  pulmonary  tuberculosis  in  children,  and,  in  rare  instances,  has 
been  associated  with  the  presence  of  a  pneumothorax.  Occasionally 
the  empyema  is  primary,  and  the  child  is  attacked  by  a  subsequent 
acute  general  tuberculosis  which  leads  to  death. 

Termination. — If  an  empyema  is  overlooked  and  remains  untreated, 
as  a  rule,  the  child  wastes  and  dies,  but  three  possibilities  are  open 
apart  from  this.  The  empyema  may  dry  up,  leading  to  fibrosis  of  the 
underlying  lung  and  bronchiectasis,  with  retraction  of  the  chest  wall. 


EMPYEMA  659 

It  may  ulcerate  into  a  bronchus  and  be  coughed  up,  though  this  happens 
more  rarely  in  children  than  in  adults;  a  cure  may  be  thus  effected,  but 
more  commonly  the  discharge  continues  until  the  condition  is  recog- 
nized and  treated.  When  such  an  occurrence  is  suspected,  it  must  be 
borne  in  mind  how  closely  the  condition  may  be  simulated  by  a  fibrotic 
lung  with  bronchiectatic  cavities,  from  which  large  quantities  of  pus, 
indistinguishable  from  the  pus  of  empyema,  may  be  expectorated. 

In  a  few  cases  the  abscess  may  open  through  the  chest  wall,  though 
this  appears  to  be  uncommon  in  childhood;  it  may  open  at  any  point, 
but  generally  does  so  in  front;  on  the  other  hand,  the  pus  has  been 
known  to  perforate  the  diaphragm  and  appear  as  a  psoas,  iliac,  or 
gluteal  abscess. 

Sequelae. — In  cases  where  complete  obliteration  of  the  empyema 
cavity  has  failed  to  occur,  owing  to  deficient  expansion  of  the  lung 
and  inability  of  the  chest  wall  by  its  contraction  to  meet  this  deficiency, 
a  discharging  sinus  remains,  and  will  not  heal  until  operative  measures, 
such  as  Estlander's  procedure,  have  closed  the  gap.  Occasionally, 
again,  a  sinus  is  caused  by  too  long  retention  of  drainage  tubes.  Such 
a  discharging  sinus,  if  left  untreated,  will  lead  to  ill-health,  and  may 
even  cause  amyloid  changes  in  the  viscera. 

In  cases  where  an  empyema  has  been  neglected  so  that  the  lung 
remains  collapsed  during  a  long  period,  and  also  where  thick  layers 
of  lymph  have  remained  and  become  organized,  pulmonary  fibrosis  is 
liable  to  occur.  The  side  of  the  chest  becomes  retracted,  and  bronchi- 
ectasis is  set  up  in  the  lower  lobe  of  the  lung. 

Diagnosis. — The  first  point  in  the  diagnosis  is  generally  that  between 
solid  lung  and  pleural  effusion.  This  has  been  left  until  the  present 
rather  than  discussed  under  the  heading  of  serofibrinous  pleurisy, 
because  empyema  is  more  liable  to  be  mistaken  for  lung  consolidation 
(and  vice  versa)  than  is  serous  effusion,  owing  to  the  earlier  age  of  the 
child,  the  association  of  the  disease  with  pneumonia,  and  the  greater 
prevalence  of  loculation  of  pus  than  of  serum  in  the  pleural  cavity 

The  diagnosis  of  a  serous  effusion  from  pneumonia  seldom  presents 
any  difficulty.  The  position  of  the  fluid  round  the  base  of  the  chest 
presents  an  unmistakable  picture,  as  does  also  the  marked  displacement 
of  neighboring  organs  when  a  large  effusion  is  present.  It  is  a  loculated 
empyema  that  may  be  so  readily  mistaken  for  pneumonia,  and  this 
may  occur  in  any  situation  save  that  it  is  rare  at  the  apex.  If  the  signs 
are  limited  to  the  apex  a  diagnosis  of  solid  lung  is  more  likely  to  be 
correct,  even  though  the  signs  incline  to  simulate  those  of  fluid.  When 
at  the  base,  the  signs  are  often  deceptive  and  many  points  need  con- 
sideration. 

Inspection  helps  little ;  the  side  may  move  well  with  fluid  or,  on  the 
other  hand,  its  motility  may  be  impaired  with  solid  lung.  Palpation 
may  give  a  valuable  clue,  since  a  fluid  thrill  is  sometimes  obtainable. 
This  is  tested  by  placing  a  hand  over  the  base  behind  while  an  assistant 
percusses  sharply  in  front,  the  sensation  obtained  being  compared  on 
the  two  sides.     A  vocal  fremitus  is  not  obtainable  in  young  children. 


660  DISEASES  OF   THE  RESPIRATORY    TRACT 

On  percussion  the  dulness  of  fluid  is  more  "wooden"  than  that  of  solid 
hnig,  and  tlie  sense  of  resistance  to  the  finger  greater.  This  is  the  most 
important  sign,  though  in  some  eases  massive  eonsoHdation  will  impart 
a  sensation  of  considerable  resistance.  The  shape  of  the  dull  area  helps 
in  certain  cases,  especially  in  its  relation  to  the  lol)ar  divisions  of  the  lung. 

Auscultation. — "NVe  have  seen  that  in  children  loud,  bronchial  breath 
sounds  may  be  heard  over  an  empyema;  more  often  they  are  somewhat 
distant,  though  bronchial  in  quality,  and  they  often  become  fainter  a-s 
the  base  of  the  chest  is  approached.  Even  when  loculated,  fluid  tends 
to  gravitate  downward,  and  the  increase  in  dulness  and  tactile  resist- 
ance, and  the  loss  of  i)reath  sounds  at  the  lowest  point  may  be  signs 
of  great  value  in  differential  diagnosis;  in  pneumonia,  on  the  other 
hand,  the  signs  of  most  advanced  consolidation  are  more  often  found 
above  the  lowest  point.  Distant  breath  sounds  at  the  base  are,  then, 
of  importance,  especially  if  these  become  progressively  louder  as  the 
chest  wall  is  ascended,  but  it  must  not  be  forgotten  that  the  breath 
sounds  may  be  suppressed  for  a  while  over  solid  lung  also.  The  vocal 
resonance  over  an  empyema  is  increased  where  bronchial  breath  sounds 
are  loud,  and,  where  these  are  distant,  which  is  generally"  at  the  ba.se, 
it  is  diminished  or  lost;  its  value  in  this  respect  conse(|uently  follows 
closely  that  of  the  breath  sounds.  There  is  another  point,  however, 
which  may  lend  importance  to  the  vocal  resonance — a  nasal  quality 
is  often  audible  over  effusions  and  is  a  valuable  distinction  when  present. 
The  simulation  of  pneumonia  by  effusions  in  children  is  due  in  most 
part  to  the  presence  of  a  consolidated  or  firm,  collapsed  lung  lying 
behind  the  fluid  layer. 

Among  general  symptoms  the  anemic  and  straw-tinted  complexion  of 
the  child  with  empyema,  the  more  moderate  rapidity  of  respirations, 
the  lower  temperature  level,  and  often  a  "glazing"  of  the  finger-ends 
preceding  clubbing,  may  lead  to  a  correct  diagnosis  where  the  signs  in 
the  lungs  arc  of  doubtful  significance. 

An  examination  of  the  blood  is  often  of  definite  value;  a  high  leukoc}i;e 
count  is  more  likely  to  indicate  a  purulent  than  a  serous  efl'usion,  and  a 
sudden  increase  in  leukocytes  during  the  course  of  a  pneumonia  points 
to  an  empyema.  Such  blood  examinations  should  never  be  neglected 
in  these  cases. 

AVhen  all  these  things  have  been  taken  into  consideration  there  still 
remains  one  test  which  should  never  be  omitted  in  case  of  doubt,  namely, 
exploratory  puncture  of  the  chest  wall.  In  some  cases  this  is  the  only 
means  of  deciding  the  diagnosis,  and  even  here  failure  is  not  infrerpient 
owing  to  blocking  of  the  needle  with  fibrin  and  the  difficulty  of  extract- 
ing fluid  under  negative  pressure.  A  large-sized  needle  should  be  used 
and  only  a  positive  result  accepted  as  conclusive. 

Pus  or  Serum. — Having  decided  upon  the  presence  of  fluid  in  the 
chest  some  attempt  may  be  made  to  decide  whether  this. is  clear  fluid 
or  pus;  in  some  cases  the  distinction  is  impossible,  in  others  there  may 
be  little  doubt.  Thus,  in  older  children  the  probability  is  in  favor  of 
serofibrinous  pleurisy,  and  if  the  history  is  short,  the  color  good,  no 


EMPYEMA  661 

suspicion  of  finger  clubbing  present,  and  if  the  fluid  is  not  loculated, 
a  diagnosis  of  this  disease  will  be  confidently  made. 

On  the  other  hand,  if  the  child  is  below  the  age  of  three  years,  espe- 
cially if  it  is  an  infant,  and  shows  marked  anemia  with  a  yellow-tinted 
skin,  if  the  history  is  long,  and  there  is  clubbing  or  great  shininess  of  the 
finger-ends  a  diagnosis  of  empyema  will  be  made  with  equal  confidence, 
and  this  especially  if  the  effusion  is  localized. 

Both  the  general  symptoms  and  the  physical  signs  must  be  considered 
in  making  a  diagnosis  between  pus  and  serum.  The  age  is  of  impor- 
tance. Empyema  is  more  common  in  infancy  (after  six  months  of  age) 
and  becomes  much  less  so  as  years  advance;  among  81  cases  at  the 
East  London  Hospital  for  Children,  nearly  35  per  cent,  occurred  during 
the  second  year,  falling  to  10  per  cent,  in  the  third  year.  Serofibrinous 
pleurisy,  on  the  other  hand,  is  rare  in  infancy  and  becomes  more  common 
when  later  childhood  is  reached.  The  duration  of  the  effusion  is  of 
some  help  in  determiuing  its  nature;  in  most  cases  a  serous  effusion 
begins  to  be  absorbed  within  ten  days  or  two  weeks  of  the  onset; 
empyemata  generally  remain  in  statu  quo  until  treatment  is  adopted. 
When  treatment  is  delayed  anemia  is  rapidly  developed,  the  muscles 
become  flabby  and  waste,  and  the  face,  and  often  the  body,  assumes  a 
yellowish  tint.  Finger  clubbing,  when  found,  is  an  important  point  in 
favor  of  purulent  effusion ;  its  commencement  is  occasionally  appreciable 
within  a  week  of  the  onset,  the  first  change  being  generally  a  peculiar 
shininess  of  the  skin  over  the  terminal  phalanges. 

The  physical  signs  in  the  chest  usually  give  less  indication  of  the 
nature  of  the  effusion  than  do  the  general  symptoms.  A  loculated 
effusion  is  always  more  likely  to  be  purulent,  except  perhaps  in  the 
region  of  the  right  middle  lobe  in  front,  where  serous  effusion  sometimes 
starts  in  children  and  remains  for  a  while  localized.  Tenderness  on 
percussion  is  more  often  noted  in  empyema  than  in  serous  effusions, 
and  edema  of  the  chest  wall  is  a  valuable  sign  of  pus,  but  is  very  seldom 
found.  Pus  is  said  to  give  a  denser  shadow  to  the  a;-rays  than  does 
clear  fluid.  As  a  rule,  the  diagnosis  between  pus  and  serum  at  the 
present  day  is  rapidly  put  to  the  final  test  of  exploration  without  much 
trouble  being  expended  on  more  subtle  points  of  diagnosis.  Some- 
times the  exploring  needle  draws  off  a  fluid  of  doubtful  nature;  it  may 
be  just  opalescent,  and  a  clot  may  form  which  is  less  transparent  than 
usual.  Microscopically,  pus  cells  are  found  in  moderate  numbers  and 
perhaps  on  culture  a  few  colonies  of  pneumococcus  develop.  Such 
cases  generally  progress  to  pus,  but  in  a  few  cases  they  undoubtedly 
recover  without  going  farther.  Cases  with  turbid  fluid  are  cases  of 
empyema  and  should  be  treated  as  such;  in  many  of  the  most  acute 
and  fatal  cases  the  fluid  is  only  thin  and  turbid.  There  is  no  doubt 
at  all  that  a  clear  serous  effusion  may  become  purulent,  but  such  a 
change  is  of  very  rare  occurrence;  when  it  occurs  the  pneumococcus 
was  generally  present  from  the  first. 

From  Fibrosis  of  the  Lung. — The  diagnosis  is  considered  under  the 
heading  of  that  disease  (p.  678). 


C62  DISEASES  OF   THE  RESPIRATORY   TRACT 

Prognosis. — This  depends  on  the  age  and  general  condition  of  the 
patioiit  and  the  pronijjtitiidc  with  whicli  treatment  has  been  carried 
out,  hut  also  hirgely  upon  tiie  origin  of  the  enij)yenia. 

The  disejise  is  very  fatal  in  the  first  year  of  life.  Among  SI  eases 
of  empyema  treated  at  the  Ea.st  London  Hospital  for  Children  11  were 
in  infants  below  one  year  of  age,  and  of  these  only  1  recovered.  The 
condition  is,  however,  not  necessarily  hopeless  in  the  youngest  children, 
since  a  case  hius  lately  recovered  in  the  same  hospital  at  the  age  of  four 
months;  such  an  occurrence,  however,  is  exceedingly  rare.  After  the 
first  year  is  past  the  chances  are  much  better.  The  total  mortality 
among  these  81  cases  quoted  was  38  per  cent.;  the  mortality  for  cases 
over  one  year  of  age  was  only  2S..5  per  cent. 

The  general  condition  of  the  child  is  necessarily  of  great  importance 
in  estimating  the  chances  of  recovery,  and  this  weighs  mostly  in  those 
cases  where  intense  anemia  with  wasting  and  general  asthenia  are  due 
to  the  presence  of  an  untreated  empyema.  Such  a  case  means,  of 
necessity,  a  prolonged  convalescence  owing  to  imperfect  expansion  of 
the  lung. 

With  regard  to  the  influence  of  the  bacteriological  result  on  the 
prognosis,  it  may  be  said  at  once  that  the  pneumococcic  cases  taken 
as  a  whole  are  by  far  the  most  favorable.  Of  my  own  cases,  mentioned 
under  the  tabular  report,  p.  ().54,  all  those  flue  to  the  staphylococcus 
died,  2  of  them  showing  a  definite  septic  source  from  which  the  infection 
had  sprung.  Of  the  3  streptococcic  cases,  1  recovered,  1  died,  and  1 
was  removed  from  the  hospital  in  statu  quo.  Of  the  3  cases  of  mixed 
pneumococcus  and  streptococcus  infection  1  was  cured  and  2  died, 
and  among  the  2  cases  in  which  the  pneumococcus,  staphylococcus,  and 
a  doubtful  bacillus  were  found,  1  recovered  and  1  died.  Thus,  among 
these  11  cases,  in  which  other  organisms  besides  the  pneumococcus  were 
present,  7  or  probably  8  died,  and  only  3  recovered.  It  is  interesting 
that  2  of  these  cured  cases  were  streptococcic,  and  I  find  another  writer 
mentions  the  fact  that  4  cases  of  streptococcic  origin  among  40  cases 
of  empyema  collected  by  himself  all  ran  a  mild  course  to  recovery. 
Thus  it  appears  that  the  streptococcus  as  a  cause  of  empyema  in  children 
is  not  such  a  virulent  organism  as  we  should,  on  other  grounds,  have 
expected. 

The  pneumococcus  cases  in  my  series  showed  a  much  lower  mortality, 
only  30  per  cent,  among  the  60  cases.  This  includes  children  of  all 
ages,  and  it  is  obvious,  from  what  has  been  said  above,  that  an  uncompli- 
cated single  empyema  in  a  child  above  the  age  of  one  year  is,  on  the 
whole,  of  good  prognosis.  Among  pneumococcic  cases,  those  in  which 
the  lung  consolidation  and  the  effusion  begin  simultaneously  are  more 
often  fatal  than  those  in  which  the  empyema  occurs  as  a  later  compli- 
cation of  pneumonia.  Cases  complicated  with  infection  of  other  serous 
membranes  are  almost  of  necessity  fatal;  such  cases  are  often  of  the 
nature  of  a  pnevunococcic  pyema  and  in  many  the  infection  is  probably 
general  from  the  beginning. 

The  position  of  the  lesion  matters  little;  the  size  is  of  less  importance 


EMPYEMA  663 

than  might  be  expected,  large  empyemata  generally  doing  well,  perhaps 
because  they  are  more  promptly  recognized.  Double  empyema  is 
distinctly  unfavorable. 

Some  writers  affirm  that  indications  of  value  may  be  gathered  from 
the  microscopic  characters  of  the  pus.  A  small  number  of  cocci  in  the 
films  is  regarded  as  favorable,  a  large  number  unfavorable;  imperfect 
staining  of  the  organisms,  moreover,  is  judged  of  good  omen,  as  is  also 
phagocytosis,  when  this  is  seen. 

Treatment. — The  treatment  of  empyema  is  the  treatment  of  an 
abscess,  though  its  peculiar  relations  to  the  thoracic  organs  renders  it 
an  abscess  of  a  rather  special  kind.  Aspiration  is  not  generally  a 
success,  and  should  only  be  used  as  a  palliative  measure,  since  the 
cavity  nearly  always  refills.  Where  the  effusion  is  large  and  causing 
much  respiratory  difficulty,  and  especially  if  for  any  reason  delay  in 
operating  must  occur,  it  is  well  to  draw  off  a  large  quantity  before  the 
operation  is  performed.  Where  more  radical  treatment  is  refused 
aspiration  must  be  tried  as  a  curative  measure.  In  double  empyemata 
an  operation  should  be  performed  at  first  on  one  side  only,  the  other 
pleural  cavity  being  emptied  or  partially  emptied  by  aspiration.  This 
may  be  repeated  if  necessary;  in  any  case  the  operation  on  the  second 
side  should  be  left  as  long  as  the  conditions  allow,  if  possible  until  the 
first  is  nearly  healed. 

The  indication  in  empyema  being  for  immediate  free  drainage  as 
soon  as  the  condition  is  recognized,  the  only  question  is  the  best  method 
of  doing  this,  the  choice  lying  between  simple  incision  between  the  ribs 
and  resection  of  a  portion  of  rib  to  allow  more  space  for  drainage.  In 
young  infants,  under  a  year  or  even  under  eighteen  months  of  age,  in 
whom  operative  measures  are  not  well  borne,  simple  incision  is  to  be 
preferred,  and,  as  a  rule,  the  drainage  afforded  is  amply  sufficient.  The 
same  applies  to  older  children,  where  the  condition  is  too  serious  to 
admit  of  an  anesthetic  being  given;  if  drainage  prove  insufficient  a 
portion  of  rib  can  be  removed  subsequently.  The  farther  forward  'the 
incision  is  made,  the  more  space  there  is  between  the  ribs;  the  further 
back,  the  better  the  drainage  in  the  supine  position.  A  point  must  be 
chosen  where  these  advantages  meet.  An  incision  one  and  a  half  inches 
long  in  the  ninth  space  at  the  posterior  or  midaxillary  line  is  generally 
convenient  from  both  points  of  view. 

In  older  children  the  removal  of  a  portion  of  rib  is  usually  necessary 
to  establish  free  drainage.  The  eighth  or  ninth  rib  in  the  posterior 
axillary  fine  is  usually  chosen,  the  rib  is  cut  down  upon,  the  periosteum 
incised  and  separated,  about  one  inch  of  rib  removed  with  bone  forceps, 
and  the  pleural  cavity  opened  above  the  incised  periosteum.  The  liquid 
pus  and  as  much  thick  fibrin  as  can  be  reached  with  the  finger  should 
be  removed.  The  operation  should  be  performed  as  soon  a,s  pus  has 
been  found  with  the  exploring  syringe,  the  only  exception  perhaps  being 
certain  cases  where  the  symptoms  are  severe  owing  to  extensive  lung 
consolidation  at  the  onset"^,  and  where  the  empyema  is  adding  little  or 
nothing  to  the  gravity  of  the  condition.     Under  such  circumstances 


664  DISEASES  OF   THE  RESPIRATORY   TRACT 

delay,  or  aspiration  as  a  temporary  measure,  may  be  wisest.  An  apical 
empyema  can  jijencrally  be  reached,  both  for  exploration  and  for  drainage, 
from  the  a])ex  of  the  axilla. 

After-treatment.  —Having  opened  the  empyema  a  large-sized  rubber 
tube  is  introduced,  or,  with  simple  incision,  two  smaller  tubes  side  by 
side  as  large  as  will  pass  between  the  ribs.  The  wound  is  dressed  with 
aseptic  dressings  and  layers  of  wool  to  absorb  the  discharge,  which  may 
be  considerable  at  first.  The  drainage  tube  should  be  removed  daily, 
boiled,  shortened,  and  reinserted.  It  is  a  common  mistake  to  retain  it 
too  long,  causing  in  many  cases  the  formation  of  a  troublesome  sinus. 
It  may  often  be  dispensed  with  at  the  end  of  a  week,  a  gauze  drain  being 
left  in  for  a  few  days  and  a  sinus  forceps  passed  in  when  the  woimd  is 
dressed  to  let  out  any  pus  that  may  be  retained.  If  drainage  seems 
inefficient  without  it,  the  tube  may  be  reinserted  for  a  few  days.  After 
first  leaving  out  the  tube,  it  is  a  good  plan  to  employ  a  wet  dressing 
for  a  few  days  to  assist  the  exit  of  pus  and  prevent  too  early  closing. 

The  surrounding  skin  should  be  kept  clean  and  dry,  an  occasional 
washing  over  with  ether  being  a  good  plan.  As  a  rule,  there  is  no  need 
for  irrigating  an  empyema  cavity;  if,  however,  the  pus  is  foul  the  cavity 
may  be  safely  washed  out  with  a  solution  of  tincture  of  iodine,  4  c.c.  to  475 
CO.  (1  dr.  to  the  pint),  but  no  force  must  l)e  used.  The  coughing  caused 
by  injection  is  very  efficient  in  removing  thick  collections  of  pus. 

The  child  should  be  got  up  as  early  as  possible  so  as  to  aid  the  expan- 
sion of  the  lungs  by  movement,  and  in  older  children  this  object  may 
be  furthered  by  an  ingenious  arrangement  of  bottles  in  which  col- 
ored water  is  blown  from  one  into  the  other;  in  private  a  trumpet  or 
some  other  form  of  wind  instrument  may  be  used  to  incite  the  patient 
to  expiratory  efforts,  for  it  is  by  expiratory  pressure  that  the  inflation 
of  the  collapsed  lung  is  brought  about. 

Many  cases  heal  in  three  weeks,  but  the  majority  take  longer,  two 
months  being  a  not  uncommon  time  limit.  When  the  cavity  does  not 
close  this  is  due  to  inability  of  the  lung  to  expand,  and  for  this  some 
definite  cause  can  generally  be  found.  In  some  the  condition  has 
remained  too  long  before  an  operation  was  performed,  and  the  lung 
is  permanently  bound  down  by  adhesions,  by  fibrous  change,  or  by 
layers  of  organized  fibrin  enclosing  its  surface;  in  others  there  is  a 
chronic  tuberculosis,  which  will  not  permit  the  full  expansion  of  the 
lung. 

When  the  lung  will  not  expand  the  chest  wall  must  be  made  to  fall 
in,  and  to  aid  this  various  operations  have  been  devised,  notably 
Estlander's,  in  which  portions  of  several  ribs  are  removed;  or  Shede's, 
in  which  parts  of  the  pleura  and  intercostal  muscles  are  also  cut  away 
to  contract  the  side  still  further.  In  some  cases  also  the  thick  layers 
of  organized  fibrin  have  been  stripped  from  the  surface  of  the  pul- 
monary pleura,  thus  allowing  the  enclosed  lung  to  expand  freely. 


PNEUMOTHORAX  665 


PNEUMOTHORAX. 


This  is  a  rare  disease  in  childhood,  since  phthisis,  which  forms  the 
common  cause  in  the  aduh,  is  of  uncommon  occurrence  in  children. 
The  majority  of  cases  in  children  appear,  nevertheless,  to  be  tuberculous 
in  origin,  other  causes  being  pulmonary  gangrene,  infarction,  emphysema, 
sometimes  in  association  with  whooping-cough,  foreign  bodies  in  the 
bronchi,  fractured  ribs,  empyema,  and  bronchiectasis.  Cnopf  describes 
three  cases  occurring  during  the  course  of  diphtheria  with  laryngeal 
stenosis,  and  in  some  of  these  emphysema  of  the  mediastinum  and 
subcutaneous  tissues  also  occurred.  A  case  due  to  tearing  of  the  lung 
by  an  adhesion  during  coughing  has  also  been  recorded. 

Symptomatology. — In  such  cases  as  occur  suddenly  there  are  shock, 
great  prostration,  dyspnea,  chest  pain,  and  weak,  rapid  pulse.  When  of 
gradual  onset  the  dyspnea  and  pain  will  be  less  severe.  Vocal  fremitus 
is  absent  over  the  pneumothorax,  but  may  be  normal  or  increased  over 
the  compressed  lung.  There  is  a  tympanitic  note  over  the  air  cavity, 
but  if  the  pleura  is  very  tense  this  will  be  less  marked,  or  even  simu- 
late dulness.  Voice  sounds  are  distant;  over  the  compressed  region 
there  is  an  amphoric  or  tubular  character  to  the  respiration.  Coins 
that  are  placed  over  the  tympanic  area  cause  a  distinct  metallic  sound 
when  tapped  together. 

The  heart  and  liver  may  be  displaced. 

When  there  is  fluid  as  well  as  air  in  the  pleural  sac  the  metallic 
tinkling  and  slushing  must  be  differentiated  from  fluid  in  the  stomach. 

Treatment.— The  treatment  is  essentially  that  of  pleurisy,  with  effu- 
sion.    Strapping  and  compression  of  the  chest  may  give  some  relief. 


CHAPTER   XXVII. 

ABSCESS  OF  THE  LUNG— GANGRENE  OF  THE  LUNG— BRONCHIEC- 
TASIS AND  PULMONARY  FIBROSIS— FOREIGN  BODIES 
IN  THE  AIR  TUBES. 

ABSCESS  OF  THE  LUNG. 

Lung  Abscesses  are  not  uncommonly  seen  on  the  autopsy  table  as 
small  multiple  foci  in  the  midst  of  pneumonic  consolidation,  but  as  a 
clinical  condition  the  disease  is  rare.  It  occurs  in  young  and  weakly 
children,  usually  as  the  outcome  of  a  croupous  pneumonia,  but  some- 
times of  a  l)ronchopneunionia. 

Symptomatology. — The  symptoms  develop  themselves  gradually  out 
of  those  of  the  primary  disease.  Thus,  an  attack  of  pneumonia  pursues 
its  ordinary  course  and  the  crisis  occurs  as  usual,  but  the  temperature 
rises  again  and  becomes  hectic.  The  bronchial  breathing,  perhaps, 
disappears  over  the  pneumonic  area,  but  tiie  dulness  remains  and 
becomes  more  marked,  so  that  a  loculated  empyema  is  usually  suspected. 
The  child  loses  weight  and  color,  sweats  profusely  in  most  cases,  and 
appears  seriously  ill.  The  temperature  generally  shows  wide  fluctuations, 
rising  high  at  night  and  falling  to  normal  or  subnormal  in  the  morning, 
and,  on  examining  the  blood,  a  leukocytosis  is  discovered,  perhaps  as 
high  as  40,000  or  50,000  per  cubic  millimetre. 

Physical  Signs. — The  signs  closely  simulate  those  of  loculated  empyema, 
namely,  dulness,  with  marked  increase  of  resistance,  and  feeble  breath 
sounds,  often  bronchial  in  cpiality,  but,  in  addition,  coarse  rfdes  and 
friction  sounds  are  generally  audible.  The  abscess  develops  in  the 
site  of  the  original  pneumonia,  and  hence  may  be  found  either  in  the 
upper  or  in  the  lower  lobe  of  the  lung. 

Diagnosis. — In  the  early  stages  the  condition  appears  to  be  nothing 
more  than  unresolved  pneumonia,  but  soon  the  continued  fever,  wasting, 
and  anemia,  and  the  generally  unsatisfactory  progress  point  to  some- 
thing further,  the  higher  leukocytosis  being  the  most  important  point 
in  the  differential  diagnosis. 

When  pus  has  collected  an  empyema  is  nearly  always  diagnosed  and 
an  operation  for  that  disease  may  reveal  the  true  condition  present, 
but  an  abscess  of  the  lung  may  be  drained  under  the  belief  that  an 
empyema  only  is  being  dealt  with.  The  diagnosis  from  empyema  is 
often  very  difficult,  since  the  marked  leukocytosis  is  common  to  both. 
Pleural  friction  occurring  over  the  dull  area  is  no  guide,  since  in  cases 
of  empyema  a  friction  rul)  is  often  audible,  being  probal)ly  produced 
over  contiguous  solid  lung.  The  absence  of  displacement  of  the  sur- 
rounding viscera  with  pulmonary  abscess  may  be  of  value  in  some 
(666) 


GANGRENE  OF   THE  LUNG  667 

cases,  but  its  occurrence  is  not  constant.  I  have  seen  the  heart  pushed 
over  by  an  abscess  of  the  left  lung  so  that  its  apex  was  close  to  the 
middle  line  of  the  chest. 

Treatment. — The  disease  runs  a  long  course,  often  of  many  months' 
duration,  and,  if  untreated,  generally  ends  in  death.  Expectoration  of 
the  pus  does  not  commonly  occur.  The  treatment  is  operative,  as  for 
abscess  elsewhere.  Pus  has  generally  been  discovered  with  the  explor- 
ing syringe,  often  with  difficulty,  and  a  rib  resection  is  undertaken  under 
the  impression  that  an  empyema  is  present.  A  healthy  pleura  being 
discovered,  if  the  surfaces  are  non-adherent,  which  is  unlikely,  the 
opening  must  be  packed  with  gauze,  or  the  lung  stitched  to  the  opening 
so  that  adhesions  shall  form  and  allow  of  further  procedure  after  a  few 
days'  interval.  Where  adhesions  already  exist  the  further  operation 
may  be  proceeded  with  at  once.  This  consists  in  again  exploring  for 
pus,  and,  when  it  is  found,  opening  the  abscess  by  boring  through  the 
lung  with  a  Pacquelin  cautery  at  dull-red  heat  or,  in  absence  of  this, 
with  a  dressing  forceps.  The  pus,  seldom  more  than  one  or  two  ounces 
in  quantity,  is  allowed  to  escape,  a  drainage  tube  inserted,  and  similar 
after-treatment  pursued  as  in  a  case  of  empyema.  Syringing  the  cavity 
should  be  avoided  if  possible,  as  this  proceeding  may  give  rise  to  con- 
siderable shock. 

GANGRENE  OF  THE  LUNG. 

This  is  a  rare  condition  and,  when  it  occurs,  it  often  remains  un- 
diagnosed during  life. 

Etiology. — The  disease  arises  as  a  result  of  many  varied  processes. 
A  number  of  cases  originate  in  bronchopneumonia,  especially  when 
this  complicates  typhoid  fever,  measles,  or  others  of  the  infective  fevers, 
or  when  an  "aspiration  pneumonia"  occurs,  generally  as  the  result  of 
a  tracheotomy.  Croupous  pneumonia  originates  some  cases,  and  many 
are  the  result  of  a  septic  embolism,  as  in  cases  of  lateral  sinus  thrombosis 
following  mastoid  disease.  Bronchiectasis  is  a  not  uncommon  cause, 
especially  when  this  is  due  to  the  presence  of  a  foreign  body  in  the 
bronchus,  a  septic  bronchopneumonia  usually  preceding  the  gangrenous 
process.     The  condition  is  sometimes  secondary  to  cancruni  oris. 

Pathology— .The  gangrenous  areas  are  very  commonly  multiple.  "\Mien 
complicating  pneumonia  they  may  be  large  in  size,  two  or  more  inches 
in  circumference  in  many  cases,  and  are  surrounded  by  consolidated 
tissue  showing  the  characters  of  bronchopneumonia  or  croupous  pneu- 
monia; when  due  to  septic  embolism  they  are  generally  scattered  and 
isolated,  perhaps  the  size  of  peas  or  cherries.  They  are  dark  brown, 
green,  or  black  in  color,  and  consist  of  soft,  shaggy  material,  of  putrid 
odor,  sometimes  leaving  a  cavity  in  the  centre  containing  blood  clot 
or  liquefied  debris.  The  gangrenous  areas  are  generally  found  near 
the  surface  of  the  lung,  and  there  may  be  some  pleurisy  over  them,  or 
an  empyema  may  have  arisen.  Softening  thrombi  are  often  present 
in  the  venous  channels  draining  the  affected  part. 


668  DISEASES  OF   THE  RESPIRATORY   TRACT 

Symptomatology. — Symptoirs  are  generally  obscure  and  may  give  no 
clue  to  the  nature  of  the  coiulitioii  present.  If  the  condition  arises  in 
pneumonia,  the  symptoms  of  tiiat  disease  are  prolont^ed,  the  temper- 
ature fluctuates,  the  cou<rh  becomes  paroxysmal,  there  may  be  chills 
and  sweating,  and  the  child  wastes  and  becomes  extremely  ill.  None  of 
these  symptoms  is  diagnostic  of  the  condition,  and  these  alone  may 
be  present;  but  in  other  cases  a  gangrenous  odor  of  the  l)reath  arises, 
and  the  characteristic  sputum,  perhaps,  appears — green,  or  dark  brown 
in  color,  blood-stained,  with  a  putrid  odor,  and  showing  fragments  of 
lung  tissue  to  microscopic  examination.  Not  uncommonly  hemoptysis 
occurs  and  may  prove  fatal,  as  in  a  case  occurring  at  the  East  London 
Ciiildren's  Hospital,  where  over  a  pint  of  blood  wtus  expectorated  imme- 
diately before  death.  The  fetid  breath  or  sputum  and  the  hemoptysis, 
when  these  occur,  should  enable  a  diagnosis  to  be  made,  in  spite  of  the 
fact  that  both  may  be  found  in  certain  cases  of  bronchiectasis  with 
pulmonary  fibrosis.  It  is  important  to  remember  that  among  cases  of 
gangrene  in  children  a  large  proportion  show  no  fetid  odor  of  the  breath. 

Physical  Signs. — The  physical  signs  are  often  those  of  pneumonia, 
but  they  may  be  those  of  bronchitis  only  in  cases  where  septic  emboli 
have  given  rise  to  multiple  gangrenous  areas  too  small  to  produce  signs 
of  consolidation.  When  an  abscess  has  formed  within  the  gangrenous 
area  and  the  contents  are  expectorated,  signs  of  cavity,  amphoric  breath- 
ing, and  pectoriloquy  may  sometimes  be  present.  In  some  cases  the 
abscess  breaks  into  the  pleural  cavity,  giving  rise  to  empyema  often 
accompanied  by  pneumothorax,  when  the  signs  of  these  diseases  will 
be  present  to  examination.  In  such  cases,  if  the  gangrenous  area  is 
single,  the  slough  may  escape  with  the  pus  when  operation  is  performed, 
and  a  cure  result. 

Treatment. — This  consists  in  operative  measures  as  soon  as  the  nature 
of  the  condition  is  recognized.  The  results  of  this  treatment  are  very 
encouraging;  Seitz  reports  Gl  per  cent,  of  recoveries  among  such  cases, 
and  remarks  that  those  in  which  the  gangrene  follows  croupous  pneu- 
monia offer  the  most  favorable  prognosis.  The  steps  of  the  operation 
required  are  similar  to  those  mentioned  under  abscess  of  the  lung.  At 
the  same  time  the  child's  strength  must  be  supported  by  tonic  remedies 
and  a  liberal  diet,  accompanied  by  alcoholic  stimulants,  and  the  fetid 
odor  controlled  by  the  use  of  inhalations  of  eucalyptus,  creosote,  or 
others  of  the  volatile  antiseptics. 


BRONCHIECTASIS  AND  PULMONARY  FIBROSIS. 

Bronchiectasis  is  so  intimately  associattvl  with  Fibrosis  of  the  Lung 
in  children  that  it  is  convenient  to  consider  it  in  connection  with  that 
disease  rather  than  with  bronchitis,  where  its  more  natural  place  would 
seem  to  be.  Fibrosis  is  always  accompanied  by  bronchiectasis,  and 
bronchiectasis  often  gives  rise  to  fibrosis,  its  presence  in  nearly  all  cases 
being  accompanied  by  some  induration  of  the  surrounding  lung  tissue; 


BRONCHIECTASIS  AND  PULMONARY  FIBROSIS  669 

at  the  same  time  when  this  fibrosis  is  small  in  amount  the  bronchiectasis 
stands  by  itself  as  a  clinical  entity,  and  as  such  demands  separate 
description. 

Bronchiectasis. — Bronchiectasis  may  be  either  temporary  or  permanent 
in  character.  Some  amount  of  dilatation  occurs  during  the  course  of  a 
prolonged  bronchopneumonia  or  bronchitis  and  may  largely  or  entirely 
disappear.  The  amount  of  recovery  depends  upon  the  duration  of  the 
attack  and  the  depth  of  the  inflammatory  process;  when  these  are 
considerable  some  permanent  enlargement  of  the  tubes  is  left. 

The  dilatation  is  either  cylindrical,  fusiform,  or  sacculated,  the  last 
being  generally  secondary  to  fibrosis  of  the  lung. 

Etiology. — The  disease  usually  dates  from  an  attack  of  broncho- 
pneumonia or  bronchitis,  very  commonly  in  association  with  whooping- 
cough  or  measles,  and  generally  affects  both  lungs,  though  it  is  nearly 
always  most  marked  on  one  side.  In  rare  cases  the  condition  is  said 
to  be  congenital. 

The  pathogeny  of  the  disease  has  been  the  subject  of  much  contro- 
versy, but  two  causes  seem  to  be  at  work  in  most  cases.  The  most 
important  of  these  is  a  softening  of  the  bronchial  wall  due  to  inflammatory 
changes.  This  is  well  illustrated  by  certain  rare  cases  where  dilatation 
of  the  smallest  tubes  throughout  the  lung^acute  bronchiolectasis — has 
occurred.  In  these  the  microscope  reveals  a  peribronchitis  associated 
in  some  cases,  but  not  in  all,  with  bronchopneumonia.  The  other  cause 
is  strain  from  increased  pressure  due  to  cough,  especially  in  the  violent 
paroxysmal  attacks  associated  with  pertussis. 

Symptomatology. — After  a  prolonged  attack  of  bronchopneumonia  or 
bronchitis,  especially  when  associated  with  pertussis,  the  cough  persists 
and  the  child  is  found  to  bring  up  a  considerable  quantity  of  sputum 
daily.  It  may  be  expectorated  with  cough,  but  often  large  quantities 
are  expelled  by  vomiting,  especially  in  young  children.  Attacks  of 
coughing  generally  occur  at  long  intervals  and  are  violent  and  par- 
oxysmal. The  sputum  is  usually  green  pus  and  sometimes  has  a  stale 
odor;  it  may,  in  rare  cases,  become  offensive,  but  this  more  often  occurs 
where  the  condition  is  associated  with  fibrosis  of  the  lung.  The  cough 
may  persist  all  the  year  round,  the  amount  of  expectoration  being  greater 
at  times,  especially  in  the  winter;  in  other  cases  the  secretion  stops  for 
a  while  in  the  summer  months  or  is  brought  up  only  once  daily,  generally 
on  rising  in  the  morning.  The  general  health  may  be  little  affected, 
and,  though  the  children  often  waste  during  the  winter  months,  they 
generally  grow  fat  under  treatment,  or  in  the  favorable  periods  of  the 
year. 

Physical  Signs. — The  signs,  when  any  are  present,  are  those  of  bron- 
chitis, with,  in  addition,  the  element  added  by  the  bronchial  dilatation. 
In  most  of  the  cases  without  fibrosis  no  definite  signs  of  cavity  are 
found,  but  the  rales  are  large,  moist  and  bubbling,  and  at  certain  parts 
of  the  chest,  especially  at  the  bases  behind  and  in  the  axillae,  may  have 
a  resonant  quality  accompanied  by  harsh  or  even  bronchial  breath 
sounds.     At  times  the  rales  have  a  dry,  rustling  quality,  not  unlike  fine 


670  DISEASES  OF   THE   RESPIRATORY    TRACT 

friction.  The  vocal  resonance  is  often  unaltered,  but  there  may  be 
bronchophony  at  some  favorable  spot.  In  the  warm  months  of  the 
year  the  mucous  membrane  of  the  dilated  tubes  secrete,s  but  little,  and 
the  signs  nearly  or  (|uite  disappear,  a  few  dry  rhonchi  perhaps  being 
heard  over  the  chest. 

Diagnosis. — The  diagnosis  from  bronchitis  is  generally  determined 
by  the  amount  of  expectoration  and  by  the  character  of  the  rales — 
their  large,  bubbling  nature,  and  the  resonant  (juality  lent  to  them  by 
the  cavity  in  which  they  are  formed.  In  bronchiecta-sis,  too,  the  signs 
are  more  localized  and  generally  more  marked  on  or  even  confined  to 
one  side  of  the  chest. 

In  any  cjise  of  marked  bronchiecta.sis,  if  one-sided,  whether  with  or 
without  definite  fibrosis,  the  possibility  of  foreign  body  a«  a  cause  must 
not  be  overlooked. 

Prognosis. — The  complications  and  prognosis  are  largely  those  to  be 
dealt  with  under  the  heading  of  pulmonar}'  fibrosis,  save  that  in  the 
absence  of  fibrosis  the  dilatation  of  the  tubes  is  seldom  so  marked  and 
their  contents  are  more  easily  expelled.  As  a  result  of  this  the  expec- 
toration more  rarely  becomes  putrid,  and  thereby  a  source  of  ill-health 
and  of  great  danger  is  avoided. 

Treatment. — The  general  health  must  be  attended  to  on  similar  lines 
to  those  about  to  be  described  under  pulmonary  fibrosis.  For  the  local 
conditions  the  emptying  of  the  cavities  and  the  relief  of  the  fetor,  if 
present,  are  the  most  important  considerations.  For  the  former  the 
effect  of  posture  may  be  taken  into  account  with  great  advantage.  By 
hanging  the  head  and  chest  over  the  edge  of  a  bed  the  cavities  empty 
bv  gravity  into  the  more  healthy  tubes  above,  violent  cough  is  induced 
and  great  cpiantities  of  phlegm  may  thereby  be  expectorated.  This 
practice  should  be  employed  at  regular  intervals  to  drain  the  passages, 
two  or  three  times  daily  being  sufficient  in  many  cases.  In  addition 
to  this  an  occasional  emetic  is  of  service  for  the  same  purpose,  and  at 
times  when  the  sputum  is  very  free  a  stimulant  expectorant  may  be 
given,  such  as  the  following,  to  a  child  of  three  or  four  years,  at  four- 
hourly  intervals: 

]^— Ammonii  carbonatis 0.06  gm.  (gr.j). 

Tincturse  scillfe 0.12  c.c.  (rnij). 

Syrupi  tolutani 1.30  c.c.  (\\\xx). 

Infusi  senegse 4  00  c.c.  (5j). 

Aqua q.  s.  ad  8.00  c.c.  (5ij).— M. 

If  the  expectoration  become  foul,  attempts  must  be  made  to  purify 
it  by  the  inhalation  of  volatile  antiseptics,  such  as  creosote,  thymol, 
eucalyptol,  etc.  They  may  be  inhaled  undiluted  from  the  surface  of 
hot  water,  or  from  a  respirator  in  the  strength  of  4.0  to  8.0  c.c.  (1  or  2 
dr.)  to  30  c.c.  (an  ounce)  of  spirits  of  chloroform,  or  carbolic  acid  may 
be  used  as  a  sprav  in  2  to  4  per  cent,  solution  by  means  of  an  atomizer. 
The  air  of  the  living-rooms  may  also  be  kept  sweet  with  a  spray  of  one 
of  these  volatile  oils  dissolved  in  rectified  spirit  (1  in  ())• 

More  efficient  is  the  method  for  creosote  inhalation  introduced  by 


BRONCHIECTASIS  AND  PULMONARY   FIBROSIS 


671 


Dr.  Arnold  Chaplin.  The  creosote  is  vaporized  in  a  small  room  and 
the  patient  endures  the  vapor  for  increasing  periods  daily,  from  one- 
quarter  hour  at  the  beginning  up  to  one  hour  at  a  sitting.  The  nostrils 
are  plugged  with  cotton-wool,  and  the  eyes  protected  with  watch  glasses 
framed  in  sticking  plaster.  The  effect  of  the  strong  vapor  is  to  cause 
effective  coughing  so  that  large  quantities  of  foul  sputum  are  expec- 
torated, and,  in  addition,  disinfection  of  the  emptied  cavities  takes 
place. 

External   drainage   of   bronchiectatic   cavities   has   been   performed, 
occasionally  with  success,  but  more  often  with  failure.    Its  employment 


Fig. 142 


Fibrosis  of  lung  in  a  girl  of  four  and  a  half  years ;  shaded  area  represents  the  contracted  left  lung; 
the  hypertrophied  right  lung  crosses  the  middle  line  hy  one  inch ;  the  position  of  the  heart's  apex 
is  indicated  by  a  cross. 

is  mainly  suitable  to  those  rare  cases  where  a  single  large  cavity  forms 
the  bulk  of  the  trouble;  as  a  rule,  the  dilatation  is  widespread. 

Pulmonary  Fibrosis.— Fibrosis  of  the  lung  of  slight  grade  is  by  no 
means  uncommon  in  children,  but  is  often  overlooked.  Many  of  these 
slighter  case§  are  the  result  of  a  former  whooping-cough  and  belong, 
perhaps,  rather  to  bronchiectasis  than  to  fibrosis,  since  the  dilatation 
of  the  bronchi  is  the  important  lesion.  The  more  marked  examples  of 
pulmonary  fibrosis  generally  own  a  different  etiology,  and  present  a 


672  DISEASES  OF   THE  RESPIRATORY   TRACT 

a  very  typical  clinical  picture  which  is  not  uncommonly  mistaken  for 
pulmonary  tuberculosis. 

Fibrosis  as  a  process  of  repair  is  a  common  accompaniment  of  many 
pulmonary  lesions;  it  is  only  when  it  occurs  on  a  wide  scale  that  its 
presence  is  recognizable  during  life,  and,  though  it  does  not  constitute 
a  disease  in  itself,  the  train  of  symptoms  and  signs  brought  about  by 
its  presence  form  a  very  definite  clinical  picture,  and  make  it  desirable 
to  group  many  cases  of  different  etiology  under  this  one  heading. 

Etiology. — The  following  table  prepared  from  82  of  my  cases,  in  which 
a  clear  history  could  be  obtained,  shows  roughly  the  common  ante- 
cedents of  pulmonary  fibrosis. 

Bronchopneumonia,  alone 6 

"  with  whooping  cough 5 

"  with  measles 3 

—  14 

Lobar  pneumonia 4 

Bronchitis,  alone 5 

with  whooping-cough .S 

'•  with  diphtheria 2 

"  with  measles  and  whooping-cough 2 

—  12 

Congenital  atelectasis    .       .       .       .     • 2 

32 

Influence  of  the  infective  fevers  among  these  cases: 

Whooping-cough,  with  bronchopneumonia 5 

"  with  bronchitis 3 

"  with  measles 2 

—  10 
Measles,  with  bronchopneumonia 3 

"       with  whooping-cough 2 

—  5 
Diphtheria .        .  2 

17 

It  is  clear  that  the  majority  of  cases  originate  in  bronchopneumonia 
and  bronchitis,  and  that  especially  when  these  are  complications  of 
whooping-cough  or  measles.  When  bronchopneumonia  is  the  starting 
point  the  attack  drags  on  to  great  length,  the  signs  never  quite  clear, 
and  when  health  returns  a  certain  amount  of  fibroid  change  is  left  in 
the  lung.  Often,  after  an  interval  of  good  health,  another  attack  of 
pneumonia  ensues  and  the  lung  is  still  further  crippled.  These  acute 
attacks  may  arise  at  intervals.  In  the  early  stages,  could  we  inspect 
the  lung,  we  should  find  a  dilated  bronchial  tree  with  thickened  walls, 
such  as  we  find  after  any  protracted  bronchopneumonia,  and,  as  the 
attacks  proceed,  inflammation  leading  to  fibrosis  spreads  from  these 
tubes  into  the  lung,  the  process  being  probably  aided  by  fibrosing  areas 
of  unresolved  consolidation  and  of  collapse.  When  the  fil)rosis  has 
become  considerable  saccular  cavitation  of  the  smaller  bronchi  appears. 
Where  lobar  pneumonia  originates  the  condition,  one  lung  only  is 
affected,  generally  part  of  a  lung,  and  the  process  may  be  limited  by 
quite  a  sharp  line  of  demarcation.  Lobar  pneumonia  is  doubtless 
responsible  for  most  of  the  apical  cases. 

In  cases  arising  in  bronchitis  I  have  observed  that  the  right  middle 
lobe  is  very  commonly  affected,  and,  seeing  the  comparative  frequency 


BRONCHIECTASIS  AND   PULMONARY  FIBROSIS  673 

with  which  collapse  occurs  in  this  part  of  the  lung  in  bronchitis,  I  am 
disposed  to  attribute  the  fibrosis  in  many  of  these  cases  to  such  collapse. 

Next  come  cases  which  originate  in  earliest  infancy  and  are  probably 
due  to  congenital  atelectasis  of  a  portion  of  lung.  The  symptoms  may 
not  appear  till  some  six  months  later.  Lastly,  an  untreated  pleurisy 
occasionally  leads  to  fibrosis  of  the  lung,  but  less  often,  I  think,  than  is 
generally  held.  When  this  occurs  it  is  in  those  cases  where  thick  layers 
of  fibrin  have  been  left  to  become  organized  in  the  pleural  cavity. 

Pulmonary  fibrosis  is  found  at  all  ages  throughout  childhood,  but 
its  origin  is  most  commonly  traced  to  the  early  years  of  life.  The  fol- 
lowing table  shows  the  age  incidence  among  38  cases  coming  under 
my  own  observation : 

Below  age  of  3  years 2  cases. 

3  to     5      '• 5      " 

5  to    10     " .        .        .        .  15      " 

10   to    15     '■ 13      " 

15    to    20      " 3      " 

38 

Of  the  2  cases  occurring  below  the  age  of  three  years,  in  one,  aged 
one  year  and  ten  months,  the  disease  was  verified  by  autopsy. 

Pathology. — On  opening  the  chest  the  lung,  if  affected  as  a  whole, 
is  found  lying  far  back  in  the  chest;  the  mediastinum  and  heart  are 
drawn  over  to  fill  the  vacant  space,  and  with  them  the  opposite  lung, 
which  is  voluminous.  When  only  part  of  a  lung  is  affected  these  changes 
are,  of  course,  much  less  marked.  The  lung  or  its  affected  part  is,  as 
a  rule,  closely  adherent  to  the  chest  wall,  though  the  pleura  may  be 
a  little  thickened  except  in  rare  cases  where  the  process  is  pleural  in 
origin.  When  the  process  is  advanced  the  lung  tissue  is  firm,  tough, 
and  elastic  to  cut;  dark,  slate-color,  or  pinkish  gray  on  section,  and 
totally  airless.  Through  it  run  the  dilated  larger  tubes;  the  smaller 
tubes  form  saccular  cavities  throughout  its  substance  and  these  often 
contain  foul  pus.  Their  walls  are  red,  smooth,  and  glistening.  The 
fibrotic  area  may  be  sharply  circumscribed,  or  the  remainder  of  the 
lung  may  show  a  less  advanced  change,  namely,  some  increase  of 
fibrous  tissue  and  moderate  dilatation  of  the  bronchi,  their  walls  being 
thickened  and  showing  as  white  lines  through  the  section.  In  cases  which 
are  primarily  and  perhaps  principally  bronchiectatic,  the  tubes  are 
thickened  and  much  dilated  in  the  lower  lobes  and  root  of  the  lungs, 
but  some  fibrous  change  is  generally  to  be  observed  around  them. 

The  lymph  nodes  connected  with  the  lung  are  enlarged  and  generally 
show  on  section  much  pigmentation,  but  little  or  no  fibrosis;  they  are 
often  quite  soft  and  pulpy. 

Histology. — The  process  by  which  a  pneumonic  area  becomes  con- 
verted into  fibrous  tissue  is  double.  There  is  an  invasion  of  the  alveolar 
walls  by  connective-tissue  cells,  and  also  a  replacement  of  the  alveolar 
exudation  by  spindle-shaped  cells  with  obliteration  of  the  lumen.  The 
same  process  occurs  where  bronchiectasis  is  the  starting  point,  fibrous 
tissue  replacing  the  inflammatory  area  around  the  dilated  tube  and 
43 


674  DISEASES  OF  THE  RESPIRATORY  TRACT 

spreading  with  each  exacerbation  farther  into  the  lung.  When  the 
condition  is  complete,  the  lung  presents  to  microscopic  examination 
strands  of  fibrous  tissue,  young  or  old,  but  mostly  cellular  and  nuclc^ 
atcd,  winding  in  various  directions,  and  enclosing  numerous  blood 
spaces.  Dilated  bronchial  tubes  are  seen  here  and  there,  some  of  them 
showing  a  round-celled  infiltration  of  their  walls.  Little  or  no  healthy 
lung  tissue  may  be  visible. 

Symptomatology. — The  onset  of  the  symptoms  varies  with  the  cause. 
When  this  is  i)ronciiitis  the  process  is  of  slow  development  and  its  stages 
ill-defined,  tiie  lung  changes  increasing  with  each  acute  catarrh.  In 
cases  beginning  with  bronchopneumonia  there  is  usually  a  frank  attack 
of  this  disease,  and  occasionally  it  appears  to  resolve  normally,  but  gen- 
erally resolution  is  delayed  and  some  signs,  a  little  impairment,  and 
some  nlles  are  left.  A  few  months  later  the  child  may  again  be  seized 
with  pneumonia,  which  settles  in  the  same  parts  of  the  lung  as  were 
involved  during  the  first  attack.  The  illness  is  protracted  over  two  or 
more  months;  the  child  remains  somewhat  weakly  or  regains  his  normal 
health,  but  is  left  with  permanent  hmg  signs.  Further  acute  attacks 
may  supervene  and  in  young  children  the  conditions  tend  to  get  worse 
and  worse,  the  child  sometimes  dying  in  one  of  the  acute  attacks  or 
from  some  complication  to  be  described  later.  In  other  cases,  espe- 
cially when  later  childliood  is  reached,  he  may  regain  his  vitality  and 
grow  up  with  a  lung  or  part  of  a  lung  contracted,  but  with  fair  general 
health.  When  lobar  pneumonia  is  the  starting  point  of  the  disease  a 
somewhat  sinn'lar  picture  of  repeated  attacks  may  be  produced,  or  the 
fibrosis  may  originate  in  a  single  unresolved  consolidation. 

The  symptoms  when  the  disease  is  establishcfl  may  be  divided  up, 
for  convenience,  into  those  characterizing  the  acute  attacks  which  so 
commonly  occur  and  those  persisting  during  the  quiescent  interval. 

Acute  aftaclcs  are  sometimes  attril)utable  to  a  definite  pneumonia; 
sometimes  they  represent  only  an  acute  l)ronchitis  of  the  dilated  tubes. 

In  the  first  case  they  are  ushered  in  with  fever  and  often  with  chilliness. 
The  cough  becomes  hard  and  dry,  the  breathing  rapid  and  distressed, 
and  there  is  generally  pain  in  the  affected  side,  which  is  worse  on  cough- 
ing. Headache  is  com])lained  of  if  the  child  is  old  enough  to  indicate 
it,  and  the  bowels  are  generally  costive,  ^\)miting  may  occur  at  the  onset, 
or  later  is  associated  with  the  expectoration  of  ])hlegm.  Streaks  of 
blood  may  appear,  or  even  a  definite  hemoptysis  occur.  The  sputum, 
which  has  perhaps  never  ([uite  ceased  in  the  interval,  now  becomes 
excessive  in  (piantity  and  may  be  of  stale  odor,  or  sometimes  offen- 
sive. Its  exjK'ctoration  is  ])receded  by  attacks  of  violent,  often  spas- 
modic, cough  at  the  end  of  which  the  sputum  is  thrown  up,  sometimes 
times  with  vomiting. 

The  child  presents  to  observation  the  appearance  of  a  case  of  })neu- 
monia.  The  face  is  flushed,  the  breathing  rapid  and  distressful,  and  he 
sits  up  in  bed  with  an  anxious  expression,  an  expiratory  grunt,  and 
working  ahe  nasi.  The  lips  are  generally  somewhat  cyanosed,  and  the 
whole  face  may  present  a  dusky  hue.    The  temperature  is  raised,  perhaps 


BROXCHIECTASIS  AXD  PULMOXARY  FIBROSIS  675 

to  101°  F.  or  more,  the  skin  is  moist  or  even  profusely  sweating,  and 
the  pulse  rapid.  This  condition  represents,  indeed,  a  pneumonia  in  the 
already  altered  lung  tissue  and  possibly  in  the  parts  around. 

If  the  child  comes  under  observation  for  the  first  time  there  may  be 
little  to  suggest  any  other  condition  than  a  simple  pneumonia,  and  the 
permanent  lung  disease,  upon  wliich  the  acute  attack  is  grafted,  may 
remain  unsuspected  until  the  latter  has  expended  itself  and  only  the 
signs  of  the  former  condition  are  left;  when,  however,  the  disease  is 
advanced  certain  permanent  records  are  at  once  observable,  notably  the 
chest  deformity,  the  displacement  of  organs,  and,  perhaps,  the  clubbed 
finger-tips,  and  these  indicate  the  true  condition.  Finger-clubbing,  to 
be  sure,  does  not  always  occur  even  with  marked  fibrosis;  it  was 
present  in  16  among  38  of   my  own  cases. 

In  other  instances,  especially  where  the  onset  has  been  insidious  from 
the  beginning,  the  acute  attack  may  be  only  a  slight  exacerbation  of 
the  existing  condition,  due  to  acute  bronchitis  with  congestion  of  the 
surrounding  lung  tissue.  The  symptoms  are  less  urgent ;  there  may  be 
little  dyspnea,  no  real  distress  or  cyanosis,  the  alae  nasi  remain  inactive, 
and  the  temperature  is  but  little  raised.  The  cough  is  the  most  trouble- 
some symptom,  and  the  expectoration,  formerly  small  in  quantity,  is 
now  brought  up  in  abundance. 

In  advanced  cases  of  fibrosis,  especially  in  older  children,  a  quite 
different  train  of  symptoms  may  bring  the  child  under  medical  care, 
namely,  those  of  cardiac  incompetence.  The  child  may  then  show 
marked  cyanosis,  with  icteric  conjunctiva,  and  dyspnea,  perhaps  amount- 
ing to  orthopnea.  Nausea  and,  perhaps,  vomiting  are  present,  and  there 
may  be  some  edema  of  the  extremities;  in  short,  the  case  presents  all  the 
symptoms  of  progressive  failure  of  the  right  heart.  On  examining  the 
chest  the  cardiac  dulness  is  found  to  be  greatly  increased,  especially  to 
the  right  of  the  sternum;  at  the  apex  the  first  sound  is  toneless  and 
accompanied  by  a  systolic  murmur,  and  the  heart's  action  is  rapid  and 
irregular.  In  such  a  case  seen  for  the  first  time  the  lung  condition  may 
be  overlooked,  and  mitral  regurgitation  due  to  organic  lesion  will  prob- 
ably be  suspected. 

In  the  acute  pneumonic  attacks  first  mentioned  the  following  signs 
are  discoverable  in  an  advanced  case. 

Physical  Signs.  Inspection. — On  examining  the  chest,  movement  is 
found  to  be  imperfect  on  one  side,  generally  at  the  base.  If  the  condition 
is  widespread,  the  whole  side  may  appear  shrunken,  the  shoulder  and 
nipple  lowered,  the  ribs  closer  together  than  usual,  and  the  spine  curved, 
with  the  concavity  toward  the  affected  side;  such  marked  deformity  is, 
however,  uncommon.  When  the  left  side  is  affected  visible  cardiac 
pulsation  may  be  observed  in  several  spaces,  owing  to  uncovering  of  the 
heart's  surface,  and  this  may  extend  out  into  the  axilla  from  displace- 
ment of  the  heart. 

Palpation. — On  palpation  the  limitation  of  movement  is  more  accu- 
rately estimated.  The  heart's  apex  beat  is  found  displaced  toward  the 
shrunken  lung,  and  the  whole  mediastinum  drawn  over.    If  the  upper 


676  DISEASES  OF   THE  RESPIRATORY   TRACT 

part  of  tlio  lung  only  is  diseased,  the  heart's  apex  is  tilted  upward; 
otherwise  this  organ  moves  over  as  a  whole  with  the  mediastinum,  its 
axis  remaining  unehanged.  There  is,  however,  in  marked  cases, 
generally  some  dilatation  of  the  right  auriele,  and  from  this  cause  the 
apex  tends  to  tilt  somewhat  upward  to  the  left.  The  vocal  vibration, 
where  this  is  obtainable,  corresponds  roughly  with  the  vocal  resonance 
to  be  mentioned  presently,  but  is  more  often  diminisheil  or  absent. 

rercussion. — Following  the  mediastinum  the  opposite  lung  passes 
over  to  the  affected  side,  and  its  resonance  may  be  found  by  percussion 
one-half  or  even  one  inch  beyond  the  sternal  margin.  The  fibroid  lung 
gives  a  flat,  wooden,  high  note  to  percussion  with  a  noticeable  increase 
of  resistance,  which  often  simulates  that  of  fluid.  The  amount  of  dulness 
depends,  of  course,  on  the  amount  of  flbrosis,  but  it  is  usually  increased 
during  the  acute  attacks.  The  percussion  note  in  other  parts  of  the  same 
lung,  or  on  the  opposite  side,  may  be  somewhat  hyperresonant. 

Auscultation. — The  character  of  the  breath  sounds  over  the  affected 
area  depends  on  the  amount  of  movement  in  the  lung,  the  size  and 
nearness  of  the  bronchiectatic  cavities,  and  also  whether  these  are 
empty  or  filled  with  secretion.  The  air  entry  may  be  feeble  or  good, 
but  during  the  acute  attack  the  quality  of  the  breath  sounds  is  always 
bronchial  and  sometimes  amphoric.  These  signs  may  be  suppressed 
temporarilv  through  blocking  of  the  tubes  with  secretion,  but  a  good 
cough  will  re-establish  them.  The  added  sounds  are  generally  bubbling, 
metallic,  resonant  rales,  but  sometimes  the  rales  have  a  dry,  rustling 
quality,  not  unlike  fine  friction. 

The  vocal  resonance  is  increased,  normal,  or  diminished,  according 
to  the  condition  present.  When  the  lower  lobes  are  affected  it  is  often 
diminished  at  the  base,  and  may  be  nasal  or  even  approaching  egophonic 
in  quality,  thus  simulating  the  condition  in  pleural  effusion;  it  may  be 
absent.  Higher  up  in  the  lung  it  is  often  increased  and,  if  the  cavities 
are  large  and  near  the  surface,  giving  tubular  or  amphoric  breath  sounds, 
bronchophony  or  even  pectoriloquy  will  be  heard.  Roughly,  it  may  be 
said  that  where  the  breath  sounds  are  merely  bronchial,  and  especially 
where  distant  and  bronchial,  the  vocal  resonance  is  diminished;  where 
the  breath  sounds  are  tubular,  or  amphoric,  the  vocal  resonance  is 
increased  or  bronchophonic. 

The  Quiescent  Period. — When  the  acute  attack  is  past  the  lung  is  left 
permanently  damaged,  but  in  a  state  of  quiescence,  and  the  symptoms 
depend  on  the  stage  which  the  process  has  reached. 

If  the  condition  is  advanced,  the  signs  are  but  little  different  from 
those  present  during  the  acute  attack.  The  dulness  may  be  less  absolute, 
the  tubular  or  bronchial  breathing  more  distant  and  less  marked,  the 
vocal  resonance  may  be  diminished  still  more,  and  the  number  of  moist 
sounds  lessened.  In  less  advanced  cases  it  is  sometimes  astonishing  how 
considerably  the  signs  will  diminish  in  the  quiescent  interval.  This  is 
especially  the  case  where  the  bronchiectasis  is  the  more  marked  feature. 
The  signs  of  dilated  tubes,  which  were  present  in  marked  degree  during 
the    attack  of    acute   consolidation,    may   entirely  disappear,   leaving 


BRONCHIECTASIS  AND   PULMONARY  FIBROSIS 


677 


only  weak    breathing  with,   perhaps,   a  Kttle   impairment  to    percus- 


sion. 


The  expectoration,  also,  even  if  abundant,  may  cjuite  disappear  in 
the  intervals,  and  in  cases  where  the  signs  of  fibroid  lung  are  marked, 
there  may  be  no  moist  sounds  audible  in  the  quiescent  stage.  In  other 
cases,  on  the  other  hand,  the  expectoration  continues  and  may  be 
brought  up  in  large  quantities  at  long  or  short  intervals.  The  children 
do  not  waste  as  in  phthisis,  but,  as  a  rule,  are  fairly  well  nourished,  and 
show  a  healthy  appetite.  This  is  especially  so  in  apical  cases,  where 
a  suspicion  of  phthisis  is  likely  to  be  entertained ;  such  children  are  often 
fat  and  rosy. 

Position  of  Lesion. — The  following  table  shows  the  position  of  the 
lesion  among  my  38  tabulated  cases : 


Eight  lung. 

Left  lung. 

Apex 
Base 
Whole       . 

.    2 

4 

.    5 

Apex 
Base 

Whole       . 

.    1 
.    5 
.16 

11 

Both  lungs 

.    5  cases. 

22 

Complications. — AVhen  the  lower  parts  of  a  lung  are  riddled  with  large 
cavities,  surrounded  by  tough,  functionless  lung  tissue  adherent  to  the 
chest  wall,  it  is  obvious  that  drainage  by  expectoration  or  occasional 
vomiting  is  bound  to  be  very  imperfect.  The  retained  secretion  tends 
to  become  foul  from  the  growth  of  numberless  saprophytic  organisms, 
and  contains  besides,  in  many  cases,  more  dangerous  pathogenic  germs. 
As  a  result  of  the  development  of  the  former  a  septic  absorption  is 
constantly  taking  place  and  greatly  undermines  the  health  of  the  patient, 
and,  as  a  result  of  the  latter,  the  patient  lives  in  constant  danger  of 
infection.  Empyema  not  uncommonly  occurs,  and  when  recognized  may 
be  successfully  treated;  bronchopneumonia  is  still  more  common,  and 
death  not  infrequently  occurs  in  the  attack.  In  the  cases  of  advanced 
fibrosis  it  attacks  the  unaffected  lung  tissues  and  sometimes  passes  on 
to  multiple  abscess  formation  throughout  the  lung,  and  occasionally 
gangrene.  Cerebral  abscess  is  an  occasional  but  well-recognized  compli- 
cation of  fibrosis  with  bronchiectasis. 

Emphysema  is  found  in  some  cases  of  fibrosis,  not  as  a  compensatory 
process  merely,  but  in  the  form  of  a  generalized  emphysema  leading 
to  the  common  deformity  of  the  chest.  Cardiac  disability  may  be  again 
referred  to  as  a  complication;  it  has  already  been  described,  under  the 
heading  of  Symptoms,  as  a  condition  which  occasionally  brings  the 
patient  under  observation.  General  tuhercidosis  is  a  fatal  concomitant 
in  some  cases,  but  bears  no  true  relationship  to  the  lung  fibrosis,  being 
but  an  accidental  complication.  Lastly,  amyloid  disease  of  the  viscera 
arises  in  some  cases,  but  appears  to  be  less  frequent  than  one  would  be 
disposed  to  expect. 

Diagnosis. — The  diagnosis  generally  has  to  be  made  from  one  of  two 
conditions— when  at  the  apex,  from  phthisis;  at  the  base,  from  pleurisy. 

The  diagnosis   from  phthisis  may  be  difficult.    Phthisis,  it  must  be 


g78  DISEASES  OF   THE  RESPIRATORY   TRACT 

remembered,  is  rare  in  children  under  six  years  of  age;  in  them 
tuberculosis  of  the  lungs  takes  a  different  form,  but  above  the  age  of 
six  vears  cases  similar  to  phthisis  of  the  adult  are  occasionally  met  with. 
The  course  of  the  disease,  as  described  by  the  friends,  often  affords  a 
valuable  clue;  in  phthisis  it  is  generally  short,  but  of  gradually  increasing 
severitv;  in  simple  fibrosis  it  often  extends  over  many  years,  the  illness 
datino-'from  a  definite  attack  of  pneumonia  or  from  the  bronchitis  of  the 
infectious  fevers. 

The  signs  in  the  lungs  generally  give  a  clue.  In  fibrosis  the  sequence 
of  lobes  so  often  followed  in  phtliisis  is  not  observed— namely,  the  apex 
of  the  upper  lobe,  the  apex  of  the  lower  lobe,  followed  by  the  apex  of 
the  upper  lobe  on  the  opposite  side.  Moreover,  in  chronic  phthisis  of 
children  considerable  cavitation  generally  occurs  and  contrasts  strongly 
with  the  more  moderate  dilatations  occurring  in  apical  fibrosis.  The 
sputum  must  be  examined  for  tubercle  bacilli.  These  can  be  demon- 
strated, if  care  is  taken,  so  that  a  negative  result  is  of  no  value.  The 
general  appearance  of  the  child  is  often  a  help  to  <liagnosis;  the  subject 
of  fibrosis  generally  presents  a  thick-featured,  somewhat  bloated  facies, 
and  is  often  well  nourished,  a  contrast  to  the  wasting  and  anemia  of 
tuberculosis. 

Basal  fibrosis  is  easily  mistaken  for  pleural  effusion.  Especially  is  it 
liable  to  be  taken  for  empyema  discharging  itself  through  the  lung, 
since  the  large  cjuantities  of  green  pus  expectorated  may  closely  simulate 
that  of  a  purulent  effusion.  The  signs  may  closely  resemble  those  of 
fluid,  resistant  dulness,  feeble  breath  sounds,  whose  bronchial  quality 
is  no  bar,  and,  perhaps,  a  diminished  or  absent  vocal  resonance.  There 
may  even  be  something  approaching  to  egophony.  Added  to  these  are 
finger-clubbing  and,  perhaps,  the  history  of  an  antecedent  pneumonia. 
Points  may  generally  be  found,  however,  to  turn  the  balance.  Thus, 
the  position  of  the  neighboring  organs — the  heart  is  displaced  by  fluid, 
drawn  over  by  fibrosed  lung,  though  even  here  a  fallacy  arises,  since  a 
chronic  pleurisv  may  cause  contraction  of  the  chest  wall  and  after  a 
time  draw  the  heart  over.  Signs  of  a  cavity  are  a  valuable  distinction, 
as  they  are  not  found  over  a  pleural  effusion ;  even  large  bubbling  rales 
are  unlikely  to  occur  with  pleurisy.  It  must  not  be  forgotten  that 
empvema  may  occur  as  a  complication  of  pulmonary  fibrosis. 

The  recognition  of  the  underlying  fibrosis  of  the  lung  during  an  acute 
pneumonic  attack  has  been  referred  to  under  the  heading  of  Symptoms. 

Prognosis. — This  depends  on  the  position  and  extent  of  the  lesion, 
and  the  age  and  station  in  life  of  the  patient.  All  the  cases  with  grave 
symptoms  have  a  basal  lesion,  whether  the  rest  of  the  lung  is  affected 
or  not;  apical  cases  generally  do  well.  Basal  cases  suffer,  owing  to 
stagnation  of  the  secretion  in  the  bronchial  cavities;  here  it  forms  a 
septic  focus  from  which  may  arise  pneumonia,  often  terminating  in 
abscess  or  gangrene,  and  pus  infections,  especially  empymea  and 
cerebral  abscess.  Foul  sputum  is  of  bad  omen,  as  it  points  to  retention 
of  the  secretion  in  the  lung  cavities,  and  the  septic  absorption  leads  to 
marked  deterioration  of  health.     It  is  often  the  beginning  of  the  end. 


BRONCHIECTASIS  AND  PULMONARY  FIBROSIS  679 

The  more  advanced  the  fibrosis  the  more  marked,  as  a  rule,  the  bronchi- 
ectasis, the  more  reduced  the  available  lung  tissue,  and  the  greater  the 
strain  on  the  pulmonary  circulation. 

Since  the  lesion  is  irremediable,  it  follows  that  if  it  starts  in  infancy 
the  outlook  is  worse  than  if  it  develops  in  the  later  years  of  childhood. 
In  the  poorer  classes,  the  exigencies  of  life  greatly  increase  the  risks  of 
those  acute  attacks  which  constitute  its  chief  danger;  among  the  well- 
to-do,  change  to  a  warm  climate  during  the  winter  months  does  much 
to  remove  the  risk  of  acute  catarrhs,  and  the  condition  is  consequently 
more  likely  to  remain  in  abeyance. 

Treatment. — The  treatment  resolves  itself  into  that  of  the  acute  attacks 
and  that  of  the  quiescent  intervals.  When  the  acute  attacks  are  due  to 
a  definite  pneumonia,  the  treatment  to  be  found  under  that  heading  will 
be  required ;  when  due  to  a  bronchitis  or  peribronchitis,  treatment  will 
be  carried  out  on  the  lines  laid  down  for  that  disease.  In  addition,  the 
heart  condition  must  be  carefully  watched,  since  the  fibrosis  causes  a 
constant  impediment  to  the  work  of  the  right  heart,  and  some  incom- 
petence is  much  more  likely  to  ensue  than  during  a  simple  pneumonia 
or  bronchitis. 

When  the  acute  attack  is  entirely  cardiac  in  origin,  as  it  occasion- 
ally is,  the  treatment  will  be  chiefly  that  employed  in  cases  of  mitral 
disease  with  loss  of  compensation. 

In  the  quiescent  intervals,  or  in  the  less  serious  exacerbations  of 
slight  and  apical  cases,  attention  must  be  directed  above  all  to  improving 
the  general  condition  of  the  child.  Such  children  can  seldom  with 
impunity  stand  the  winter  of  a  harsh  climate,  and,  where  circumstances 
permit,  it  is  well  to  move  them  for  the  colder  months  of  the  year  to  some 
spot  where  abundant  sun  and  still,  dry  air  are  obtainable.  Under  such 
conditions  they  can  live  much  in  the  open,  and  thereby  they  avoid  to 
a  large  extent  those  catarrhs  which  are  both  dangerous  in  themselves 
and  also  tend  to  further  the  progress  of  the  disease.  Cod-liver  oil,  with 
iron  or  malt,  is  often  useful,  especially  if  creosote  be  added.  Guaiacol 
may  be  used  instead,  and  a  preparation  I  have  found  of  the  utmost 
value  is  thiocol,  a  creosote  derivative  which  is  alike  tasteless,  freely 
soluble,  and  readily  borne  by  the  weakest  digestion.  It  may  be  given 
in  doses  beginning  at  0.2  to  0.3  gm.  (3  to  5  gr.)  for  children  a  few 
years  old,  and  may  be  largely  increased,  though  the  small  doses  are 
often  quite  efficient  in  improving  nutrition  and  the  general  well-being. 
It  is  best  prescribed  with  syrup  of  orange,  or  syrup  of  iron  phosphate, 
with  or  without  dilution  with  water,  but  these  may  be  omitted  if  they 
upset  digestion. 

When  the  secretion  is  abundant  and  difficult  to  bring  up,  the  effect 
of  posture  may  be  taken  advantage  of  in  clearing  the  tubes ;  in  addition, 
an  occasional  emetic  may  be  given  and  a  course  of  stimulating  expec- 
torants employed.  These  methods  have  been  already  described  under 
the  heading  of  Bronchiectasis,  as  has  also  the  treatment  of  fetid  expec- 
toration by  the  inhalation  of  volatile  antiseptics,  or  by  creosote  vapor 
after  the  method   described   as   introduced   by   Dr.   Ai-nold   Chaplin. 


680  DISEASES  OF   THE  RESPIRATORY   TRACT 

External  drainage  is  less  applicable  to  cases  of  pulmonary  fibrosis  than 
to  simple  bronchiectasis,  owing  to  inability  of  the  surrounding  parts  to 
fall  in  and  close  the  discharging  cavity. 


FOREIGN  BODIES  IN  THE  AIR  TUBES. 

The  entrance  of  a  foreign  body  into  the  air  tubes  is  an  accident  of  not 
very  rare  occurrence  in  young  children.  The  objects  inspired  have 
been  very  various,  and  include  such  examples  as  a  glass  bead,  a  pill, 
a  bean  or  seed,  the  peg  of  a  top,  a  fruit-stone  or  grain  of  corn,  and  a 
bone  from  soup.  These  were  the  foreign  bodies  found  in  a  series  of 
cases.  In  addition,  a  caseous  lymph  node  nuiy  ulcerate  into  a  bronchus 
and  cause  blocking  of  its  lumen. 

Symptomatology. — A  common  history  is  that  the  child  is  playing  with 
his  toys,  or  otherwise  amusing  himself,  when  he  is  suddenly  seized 
with  a  violent  fit  of  coughing  and  choking,  during  which  he  turns  purple 
in  the  face  and  gasps  for  breath.  The  attack  lasts  a  variable  period, 
sometimes  as  much  as  fifteen  minutes,  and  then  passes  off,  and  the 
child  may  be  quite  comfortable  for  a  time,  but  generally  a  second 
similar  attack  occurs  after  an  interval.  These  attacks  of  coughing  may 
be  repeated  indefinitely,  the  child  being  comfortable  in  the  interval, 
and  he  is  sometimes  thought  to  be  suffering  with  whooping-cough, 
which  the  paroxysms  may  closely  simulate  even  to  the  accompanying 
"whoop."  In  cases  where  the  body  becomes  immediately  impacted,  no 
recurrence  of  the  initial  attack  may  occur. 

Occasionally  the  foreign  substance  is  expelled  during  an  attack;  more 
often  it  remains.  The  position  of  the  impaction  in  the  tubes  and  the 
results  of  its  presence  there  depend  upon  its  size,  shape,  and  consistence. 

If  large,  it  may  block  the  larynx  and  lead  to  immediate  death,  as 
occasionally  occurs  from  impaction  of  a  lump  of  meat.  If  small,  it 
may  become  lodged  in  the  ventricles  of  the  larynx,  leading  to  symptoms 
resembling  laryngitis  stridulosa,  but  more  commonly  it  enters  a  bronchus, 
generally  the  right,  and  either  remains  loose,  when  it  is  coughed  up 
against  the  vocal  cords  and  causes  attacks  of  spasm,  or  becomes  impacted 
in  the  tube.  In  the  first  case  it  may  be  heard  to  move  up  and  down 
during  coughing,  and,  if  the  larynx  is  palpated,  the  vibration  of  its 
impact  on  the  vocal  cords  may  be  distinctly  appreciated.  When  it  is 
impacted  in  the  bronchus,  the  symptoms  will  depend  on  its  shape.  If 
it  is  spherical,  like  a  bead  or  bean,  it  may  completely  block  the  tube. 
In  this  case  the  air  entry  and  respiratory  movement  will  cease  over  the 
affected  part,  which  may  be  the  w'hole  lung  or  only  one  lobe,  the  blocked 
area  will  collapse,  and  the  heart  and  mediastinum  move  over  toward  it. 
If  the  body  is  irregular  in  shape,  and  does  not  obstruct  the  passage  of 
air,  no  pulmonary  collapse  results,  but  ulceration  is  set  up  by  its  pressure, 
followed  by  an  acute  bronchitis  of  the  tubes  below. 

In  either  case  the  outlook  is  now  very  serious ;  a  septic  bronchopneu- 
monia, or  abscess  or  gangrene  of  the  lung  may  be  set  up,  especially 


FOREIGN  BODIES  IN   THE  AIR    TUBES  681 

where  the  foreign  body  is  of  a  nature  to  undergo  decomposition,  but  in 
more  favorable  cases  bronchiectasis  of  the  tubes  below  the  obstruction 
takes  place,  the  lung  becomes  fibrosed,  and  the  abundant  secretion 
retained  in  the  dilated  tubes  generally  becomes  fetid. 

In  some  cases  the  presence  of  a  foreign  body  is  quite  unsuspected, 
the  child  being  brought  some  years  after  the  accident  on  account  of 
the  expectoration  of  foul  pus.  On  examination  a  unilateral  fibrosed 
lung  with  bronchiectasis  is  found,  and  by  questioning  the  parents  a 
history  of  whooping-cough  at  the  onset  may  be  elicited.  This  seems 
to  agree  well  with  the  etiology  of  a  simple  fibrosis  of  the  lung,  and  it 
may  well  be  overlooked  that  the  so-called  "whooping-cough"  repre- 
sented in  reality  the  spasmodic  attacks  set  up  by  the  foreign  body 
before  it  became  impacted.  In  some  such  cases  an  empyema  appears 
outside  the  fibroid  lung,  and  instances  are  recorded  where  a  superficial 
abscess  in  connection  with  the  foreign  body  has  formed  over  the  chest 
wall. 

The  physical  signs  are  not  peculiar  to  the  presence  of  a  foreign  body, 
but  vary  according  to  the  condition  it  sets  up.  When  a  main  bronchus 
or  large  division  is  completely  blocked,  at  first  the  lung  is  resonant,  but 
the  respiratory  movement  is  lost,  and  the  breath  sounds  absent.  In 
some  cases  the  body  may  become  loosened  by  cough  and  the  normal 
signs  reappear  for  a  moment  to  disappear  again  presently.  This  is 
pathognomonic  of  the  presence  of  a  foreign  body  in  the  bronchus. 
After  a  time  the  imprisoned  air  in  the  lung  is  absorbed,  it  collapses,  the 
percussion  note  becomes  impaired  or  dull  over  it,  and  the  heart  and 
mediastinum  move  over  toward  the  affected  side.  Where  the  bronchus 
is  not  completely  blocked,  the  air  entry  may  be  poor  over  the  lobe  or 
lobes  connected  with  it,  and  there  are  found  the  signs  of  bronchitis 
localized  to  the  affected  parts,  these  last  appearing  very  rapidly  after 
the  onset. 

When  bronchopneumonia  or  pulmonary  abscess  supervenes  the  signs 
belonging  to  those  diseases  will  be  present.  If  bronchiectasis  is  set  up, 
the  symptoms  of  this  disease  generally  appear  in  a  few  weeks'  time, 
though  the  sputum  may  not  become  foul  for  a  year  or  two  after  the 
onset  in  cases  where  the  foreign  body  is  smooth  and  clean;  where  it  is 
of  an  irritating  nature,  or  capable  of  decomposition,  the  sputa  become 
rapidly  fetid.  In  these  cases  the  physical  signs  are  those  of  unilateral 
bronchiectasis  and  fibrosis,  and  the  reader  is  referred  back  to  the 
description  of  these  diseases. 

Diagnosis. — This  depends  upon  the  sudden  onset  of  symptoms  of 
choking  in  a  healthy  child,  followed  by  the  signs  and  symptoms  described 
above,  and  in  some  cases  the  nature  of  the  article  is  known  or  suspected. 
When  the  body  is  loose  in  the  tubes  its  movements  may  be  heard  or 
palpated.  Where  the  symptoms  are  those  of  laryngitis  the  history  of 
onset  will  generally  determine  the  diagnosis.  In  cases  where  a  so-called 
"fit"  has  occurred  during  the  progress  of  a  meal,  and  the  patient  is 
found  to  be  half  asphyxiated  or  unconscious,  the  larynx  should  be  at 
once  explored  with  the  finger  on  the  suspicion  of  food  impaction.  Where 


682  DISEASES  OF   THE   RESPIRATORY    TRACT 

a  unilateral  bronchiectasis  and  fibrosis  are  found,  especially  if  the  expec- 
toration is  fetid,  the  symptoms  of  its  onset  should  bo  carefully  invest- 
igated, and  the  nature  of  any  initial,  so-called  "whooping-cough" 
ascertained.  Examination  by  .r-rays  will  in  some  instances  lead  to  a 
correct  diagnosis. 

Prognosis. — The  prognosis  is  bad  if  the  foreign  body  remains  in  the 
tubes,  though  there  is  a  chance  that  it  may  l)cc()mc  loosened  and  be 
removed  by  cough.  If  this  does  not  happen  a  fatal  issue  nuist  be 
expected,  though  an  interval  of  many  years  may  pass  when  the  foreign 
body  is  some  clean  and  smooth  article  such  as  a  glass  bead  or  the  peg 
of  a  top.  In  cases  where  sharj)  and  angular  bodies  are  impacted,  espe- 
cially when  liable  to  decomposition,  as  was  the  soup-i)one  cited  above, 
the  outlook  is  very  unfavorable.  Septic  trouble  is  liable  to  intervene 
and  lead  to  death.  When  the  foreign  body  is  removed  the  prognosis 
depends  on  the  amount  of  permanent  damage  left  behind,  but  even 
considerable  bronchiectasis  is  compatible  with  good  general  health. 

Treatment. — At  the  onset  the  patient  should  be  inverted  and  shaken. 
This  is  not  often  successful,  as  the  object  can  seldom  pass  the  glottis, 
and  urgent  laryngeal  spasm  may  be  set  up.  When  the  presence  of  a 
foreign  body  is  decided  upon,  immediate  steps  for  its  removal  must  be 
taken.  Tracheotomy  should  be  performed  and  the  child  again  inverted 
and  shaken;  this  is  generally  successful;  if  it  is  not  the  wound  must  be 
kept  open,  the  edges  being  retracted  with  the  aid  of  an  elastic  band 
round  the  back  of  the  neck.  By  this  means  the  body  will  be  coughed 
out  through  the  opening  if  it  becomes  loosened,  though  sometimes  it 
passes  through  the  glottis  and  is  swallowed.  If  it  remains,  after  an 
interval  an  attempt  may  be  made  to  grasp  it  with  a  fine  forceps  if  its 
presence  is  undoubted.  It  will  usually  be  found  at  the  bifurcation  of 
the  trachea,  or  in  one  or  other  bronchus,  generally  the  right  on  account  of 
its  larger  size,  and  in  the  inclination  of  the  dividing  spur  to  the  left  side. 

In  cases  where  the  patient  is  first  seen  after  bronchiectasis  has  been 
set  up  the  necessity  for  operative  measures  must  be  discussed,  since  the 
condition  is  certainly  fatal  if  the  foreign  body  remain.  Having  localized 
the  position  of  a  large  dilated  tube,  a  piece  of  rib  is  resected  at  a  chosen 
spot  over  it,  and  the  lung  stitched  to  the  wound  unless  adhesions  between 
the  pleural  surfaces  already  exist.  After  a  few  days  the  bronchiectatic 
cavity  is  opened  with  a  Pacquelin  cautery  at  dull-red  heat,  and  an 
attempt  made  to  find  the  foreign  body.  This  is,  of  course,  impacted 
above  the  cavity,  and  if  it  is  not  found  a  large  drainage  tube  must  be 
left  in,  since  it  is  sometimes  expelled  through  the  wound  subsequently 
during  coughing.  When  the  operation  is  unsuccessful,  it  is  recom- 
mended to  })erform  tracheotomy  and  explore  the  bronchi,  or  to  open 
the  pleural  cavity  elsewhere  and  examine  the  surface  of  the  lung  with 
the  finger.  When  the  foreign  l)ody  is  found  and  removed  the  general 
health  may  be  largely  or  entirely  regained,  the  expectoration  becomes 
less  in  quantity  and  loses  its  fetor,  and  the  case  becomes  one  of  ordinary 
basal  bronchiectasis  and  fibrosis,  whose  treatment  has  been  already 
considered. 


SBCTIOK    VIII. 
DISEASES  OF  THE  HEART  AND  BLOODVESSELS. 

By  F.  J.  POY^'TOX,  M.D.,  F.R.C.P.,  London. 


CHAPTER  XXYIII. 

METHOD  OF  EXAMINATION— CONGENITAL  HEART  DISEASE— 
RHEU^LITIC  HEART  DISEASE. 

THE  CLINICAL  EXAMINATION  OF  CHILDREN  WITH  HEART 

DISEASE. 

The  examination  of  a  child  must  be  methodical.  Only  by  this  means 
can  rapidity  and  accuracy  of  diagnosis  be  eventually  achieved.  This 
accuracy  is  the  more  needed  because  heart  disease  in  the  child  is  much 
more  common  than  the  general  public  believe,  and  the  symptoms  are 
not  always  appreciated  by  the  medical  man  in  attendance. 

The  aspect  of  the  face  will  naturally  first  attract  attention.  Is  it 
flushed  with  a  purple  tinge  as  in  mitral  stenosis  ?  is  it  pale  as  in  aortic 
regurgitation?  is  it  distressed  as  in  pericarditis,  or  blue  as  it  is  in  con- 
genital disease? 

The  physician  will  soon  see  if  the  breath  is  short,  and  should  not 
mistake  the  way  in  which  such  children  spare  their  words  for  taciturnity. 
He  will  look  at  the  hands,  note  the  color  of  the  nails  and  the  shape  of 
the  tips  of  the  fingers,  and  then  examine  the  pulse. 

The  Pulse. — This  should  not  be  described  in  a  loose  way  as  soft  or 
hard,  but  under  these  headings: 

1.  Rate.  2.  Regularity  in  force  and  frequency.  3.  Character  of  the 
wave:  (a)  Well  or  ill  sustained,  (b)  Size,  large  or  small,  (c)  Com- 
pressibility, (d)  Felt  or  not,  between  the  beats.  4.  The  condition  of 
the  arterial  wall.     5.  Any  special  peculiarities. 

The  chest  is  now  examined.  First  the  heart,  by  inspection,  palpation, 
percussion,  and  auscultation,  and,  if  necessary,  by  radiography.  After 
the  heart  the  lungs  will  be  investigated,  and  the  vessels  in  the  neck 
can  be  observed. 

The  abdominal  organs  are  next  investigated  and  three  special  points 
are  noted:  1.  The  condition  of  the  hver.  2.  The  condition  of  the 
spleen.     3.  The  presence  or  not  of  ascites. 

( 6S3 ) 


684  tUSEASES  OF   THE  HEART  AM)   BLOODVESSELS 

The  lower  extremities  are  examined  to  settle  the  question  of  edema, 
and  then  other  points  which  iiave  hearinj^  npon  the  case  are  attended  to, 
as,  for  example,  the  presence  of  nodules  or  arthritis,  or  the  slight  inco- 
ordination of  an  early  chorea. 

The  urine  is  always  to  be  tested. 

Lastly,  it  is  an  excellent  plan  to  have  a  stamp  outline  of  the  chest 
and  abdomen  on  which  the  chief  results  of  this  examination  can  be 
recorded  (Fig.  143). 

Fig. 143 


Stamp  outline  used  in  making  notes  in  heart  disease. 

The  Position  of  the  Heart  in  Childhood.— The  heart  of  the  child 
lies  higher  in  the  chest  than  that  of  the  adult,  and  the  precordial  area 
is  more  variable. 

The  apex  impulse  in  the  infant  is  often  indeterminable.  Up  to  about 
six  years  it  is  situated  in  the  fourth  intercostal  space;  after  seven,  in  the 
fifth.  The  area  of  relative  dulncss  always  reaches,  as  in  the  adult,  to 
the  right  of  the  sternal  margin,  but  it  extends  farther  to  the  left,  reaching 
the  vertical  nipple  line,  and  even  passing  beyond  it  in  the  first  six  years 
of  life.  Under  six  years  of  age  the  upper  limit  is  usuallv  at  the  second 
interspace  to  the  left  of  the  sternum,  and  after  six  years  the  third  rib. 

The  relative  dulness  is  the  important  area  of  dulness  and  needs 
careful  light  percussion  for  its  determination. 

I  believe  in  the  finger  as  a  pleximeter,  and  though  I  am   convinced 


METHOD   OF  EXAMINATION  '  685 

of  the  very  great  importance  of  careful  percussion,  it  is,  in  my  experience 
but  a  partial  assistance.  To  draw  important  conclusions  from  minute 
differences  in  the  percussion  outline  of  the  heart  is  dangerous.  In  no 
diseases  more  than  in  those  of  the  heart  in  childhood  is  it  more  necessary 
to  take  a  broad  survey  of  the  case,  and  to  steadfastly  refuse  to  be  led 
into  forming  one's  judgment  from  one  physical  sign  alone,  be  it  an 
area  of  cardiac  dulness  or  a  bruit.  Symptoms  in  heart  disease  are 
often  more  important  than  physical  signs,  and  this  truth,  impressed 
upon  me  by  my  honored  teacher,  Sir  William  Broadbent,  is  a  very 
great  one. 

HEART  DISEASE  IN  CHILDHOOD. 

Some  Peculiarities  in  the  Heart  Disease  of  Childhood. — When,  in 
general  terms,  a  comparison  is  drawn  between  affections  of  the  heart  in 
the  child  and  in  the  adult,  certain  differences  are  apparent.  In  the  child 
the  symptoms  are  often  remarkably  latent,  while  breathlessness  in  a 
child  means  more  than  the  same  in  an  adult.  Wasting  is  a  more 
prominent  symptom  in  the  child.  Children  have  less  pain  and  anxiety 
and,  except  in  diphtheria,  sudden  death  is  extremely  rare.  Great  edema 
is  exceptional,  but  slight  edema  of  the  face  is  more  common  than  in  the 
adult.  The  pulse  is  a  more  uncertain  guide  in  the  child,  for  it  is  more 
easily  influenced  by  fright  and  nervousness.  Pericarditis  is  more  com- 
mon, and  the  lesions  of  endocarditis  are  often  multiple.  The  heart, 
as  a  whole,  is  more  often  damaged,  and  carditis  or  a  relapsing  carditis 
much  more  frequent. 

Hypertrophy  is  rapidly  and  effectually  accomplished,  but  the  greater 
liability  to  repeated  attacks  of  rheumatism  leads  to  frequent  break- 
downs in  compensation,  which  often  stultify  the  value  of  the  hypertrophy. 
A  child  with  advanced  valvular  disease  is  much  less  of  an  invalid  than 
an  adult.  The  frequency,  however,  of  pericarditis  and  the  occurrence 
of  pericardial  adhesion  in  early  life  add  to  the  difficulties  with  which 
they  have  to  contend.  Degenerative  affections  of  the  heart  and  blood- 
vessels are  practically  non-existant;  nor  does  overstrain  play  the  part 
in  causation  that  it  does  in  adult  life.  On  the  other  hand,  infections 
are  much  more  liable  to  cause  heart  disease  in  the  young. 

Etiology.  General  Considerations. — In  considering  the  etiology  of 
heart  disease  in  childhood  it  is  usual  to  divide  the  subject  into  two  great 
groups:  1.  Congenital  heart  disease.  2.  Acquired  heart  disease.  This 
is  a  chnical  division  of  practical  value,  though  it  is  apparent  on  closer 
inquiry  that  the  distinction  is  not  always  a  scientific  one. 

1.  Congenital  Heart  Affections. — These  are  in  part  the  result  of  arrest 
in  development  of  an  organ,  which  is  gradually  evolved  from  a  simple 
tube  into  a  complicated  four-chambered  pump,  supplying  an  intricate 
system  of  vessels,  and  partly  the  result  of  disease  attacking  this  organ 
through  the  medium  of  the  placental  circulation  of  the  mother. 

2.  Acquired  Forms  of  Heart  Disease. — It  is  an  encouraging  fact  that 
the  causes  of  acquired  heart  disease  are  generally  definite  ones.  The 
vast  proportion  of  them  result  from  infective  processes.    This  fact  must 


686  DISEASES  OF   THE  HEART  AXD  BLOODVESSELS 

make  a  writer  upon  this  subject  long  for  an  inspired  pen  to  arouse  in 
his  readers  an  enthusiastic  desire  to  study  their  prophyhixis.  With  the 
demonstration  of  the  infective  nature  of  rheumatic  fever  much  of  the 
obscurity  that  hitherto  existed  has  faded  away,  and  the  tttsk  of  giving 
a  clear  description  of  the  subject  is  greatly  lightened. 

Rheumatism  is  the  chief  cause  of  ac(juired  heart  disease,  the  channel 
of  infection  in  many  cases  being  through  the  inflamed  tonsils.  A 
history  of  rheumatism  following  a  sore  throat  is  very  common,  a  fact 
that  for  over  a  century  has  been  recognized  by  clinicians.  In  1900 
Dr.  Paine  and  I  produced  the  lesions  of  rheumatic  fever  in  rabbits  by 
subcutaneous  inoculations  with  a  diplococcus  isolated  from  a  case  of 
rheumatic  angina.  This  micro-organism  we  had  previously  isolated  and 
demonstrated  in  the  chief  lesions  of  rheumatic  fever. 

Clever  independently  arrived  at  the  same  conclusion  by  a  study  of 
rheumatic  angina,  and  it  seems  certain  that  the  tonsil  is  a  channel  of 
infection.  It  Ls  disputed  whether  one  or  various  infections  may  cause 
rheumatic  fever,  l)ut  at  the  present  time  there  is,  in  my  opinion,  no 
positive  proof  of  the  existence  of  more  than  one  microbic  agent — a 
diplococcus  of  the  streptococcal  group — a  fact  previously  suspected  by 
many  observers.  Rheumatic  fever  is,  no  doubt,  more  common  and 
more  virulent  in  E^ngland  than  in  America,  and  for  this  reason  is  a  more 
important  factor  in  the  causation  of  heart  (Hsease  in  the  former  country. 
In  childhood  it  is  peculiarly  liable  to  attack  the  heart,  and  the  physician 
should  not  overlook  the  danger  from  mild  attacks  of  rheumatism. 

Scarlet  fever  is  another  important  cause,  but  the  nature  of  the  infection 
of  scarlet  fever  is  much  disputed;  and  though  some  hold  it  to  be  the 
result  of  a  streptococcal  invasion,  others  look  upon  the  damage  to  the 
heart  either  as  truly  rheumatic  or  in  other  cases  as  being  due  to  a 
streptococcal  infection  which  is  a  complication  and  not  the  true  cause 
of  the  scarlet  fever. 

Diphtheria  damages  the  heart  in  a  considerable  proportion  of  cases 
by  the  action  of  its  poisons  upon  the  myocardium,  rather  than  from 
the  deposition  of  the  bacilli  in  the  valves  and  pericardium. 

Tuberculous  infection  is  another  factor,  but  not  a  very  common  one, 
and  perhaps  more  frecjuently  met  with  in  America  than  in  England. 

Influenzal  infection  attacks  the  heart,  and,  although  it  is  the  elderly 
who  are  the  chief  sufferers,  still  there  is  clear  evidence  that  children 
may  also,  to  a  lesser  degree,  be  damaged  by  this  effect  of  the  disease. 

The  pneumococcus,  streptococcus  pyogenes,  cfonococcus,  Tnenincjococciis, 
and  staph  i/lococcus  a  ureus,  singly  or  in  mixed  infection ,  occasionally  attack 
the  heart,  but  the  frequency  of  the  occurrence  will  not  compare  with 
that  of  the  rheumatic  infection. 

There  are  examples  of  heart  disease  after  measles,  chicken  pox, 
typhoid  fever,  and  pertussis,  and,  in  some  cases,  congenital  syphilis  is 
claimed  as  a  cause. 

Predisposing  Causes. — Enough  has  been  written  to  show  what  a 
prominent  part  infections  play  in  the  causation  of  heart  disease,  but  the 
predisposing  causes  are  also  of  great  importance. 


METHOD  OF  EXAMINATION  ggy 

Among  them  heredity  stands  first,  for  it  is  a  powerful  factor  in  rheu- 
matism. The  seasons  of  the  year  in  which  heart  disease  is  most  Hkely 
to  commence  are  the  autumn  and  the  spring. 

Damp,  and  especially  cold  damp,  overcrowding,  and  malsanitation  all 
lower  vitality  and  predispose  to  tonsillar  inflammations.  Carious  teeth, 
with  alveolar  inflammation,  chronic  otitis  media,  and  other  chronic 
discharges  are  all  sources  of  danger  which  may  permit  infection  by 
bacteria  that  have  the  power  to  produce  heart  disease,  but,  as  the  late 
Dr.  Packard  pointed  out,  it  would  be  a  mistake  to  accept  every  infection 
of  the  heart  entering  from  the  mouth  or  upper  air  passages  as  neces- 
sarily rheumatic  in  nature. 

When  renal  disease  is  considered,  the  questions  involved  are  more 
complex.  The  heart  is  often  damaged,  and  the  damage  may  occur  in 
two  different  ways.  A  child  may  fall  ill  with  nephritis,  peritonitis,  and 
pericarditis,  a  result,  let  us  suppose,  of  a  pneumococcal  infection;  in  this 
case  the  nephritis  and  pericarditis  are  results  of  this  infection,  and  the 
pericarditis  is  not  dependent  upon  the  nephritis.  Again,  in  rheumatism 
the  diplococcus  can  be  found  in  the  kidney  and  may  cause  nephritis 
as  well  as  carditis.  But  there  is  also  in  renal  disease,  especially  of  the 
chronic  type,  a  retention  of  poisons  which  produce  important  effects 
upon  the  heart  and  bloodvessels,  and  it  is  this  group  of  cases  which  is 
especially  associated  with  renal  disease.  Nevertheless,  the  subject  is 
obscured  by  the  occasional  supervention  of  an  acute,  infective  pericar- 
ditis, even  in  these  chronic  cases. 

Overstrain  will  damage  the  hearts  of  young,  anemic,  rapidly  growing 
children.  When  a  child  is  healthy  it  takes  a  great  deal  to  damage  this 
organ,  and  it  is  very  necessary  not  to  get  an  exaggerated  idea  of  the 
influence  of  overstrain.  It  will  be  an  evil  day  when  the  heart  specialist, 
who  has  never  perhaps  been  young  himself,  undertakes  to  arrange  the 
exercise  of  a  healthy  boy.  But  where  there  is  imperfect  convalescence 
from  some  acute  infection,  such  as  influenza  or  diphtheria,  then  there 
is  danger.  Underfed  and  growing  lads,  who  bicycle  about  as  messengers 
and  errand  boys,  or  who  train  for  races  after  a  hard  day's  work,  are 
liable  to  strain  the  heart;  as  also  will  delicate,  high-spirited  boys  who 
are  sent  for  long  runs  or  made  to  exercise  beyond  their  strength. 

Where  there  is  already  organic  heart  disease,  the  influence  of  over- 
strain is  a  much  more  dangerous  one  and  may  bring  about  a  very 
serious  breakdown.  Thus,  at  a  time  when  bicycHng  was  the  madness 
of  the  hour  in  this  country,  a  boy  with  advanced  mitral  stenosis  went 
for  a  long  ride  upon  a  hot  day;  the  result  was  that  he  collapsed  with 
extreme  tachycardia  from  which  he  took  months  to  recover,  and  came 
very  near,  indeed,  to  losing  his  life. 

Anemia  in  childhood  intensifies  the  effect  of  any  cause  which  produces 
organic  heart  disease,  and  when  it  is  very  profound  enfeebles  the  cardiac 
muscle  to  such  a  degree  that  it  becomes  a  danger  in  itself.  More  often, 
perhaps,  by  the  production  of  loud  functional  murmurs,  it  causes  diffi- 
culty by  raising  the  question  whether  these  murmurs  are  not  in  reality 
organic  and  dependent  either  upon  congenital  or  acquired  heart  disease. 


688  DISEASES  OF   THE  HEART  AND  BLOODVESSELS 

Nervous  influences  arc  important  in  the  clinical  study  of  heart  disease 
in  childhood.  Chorea,  I  look  upon  as,  in  most  instances,  if  not  in  all, 
rheumatic  in  origin,  and  in  this  article  the  affections  of  the  heart  which 
occur  with  chorea  are  considered  under  the  heading  of  Rheumatism. 
Hut  it  w»)uld  be  an  error  to  lose  sight  of  the  detrimental  effects  of  shock, 
fright,  and  evil  habits  upon  the  heart.  Irregularity  of  action,  palpita- 
tion and  rapidity,  are  common  results  of  these  influences,  and  a  sudden 
fright  may  cause  even  fatal  syncope. 

Pulmonarii  affections,  ;is,  for  exaTnj>le,  asthma  or  repeated  bronchitis 
with  emphysema,  may,  even  in  childhood,  so  greatly  tax  the  right  side 
of  the  heart  as  to  cause  tricuspid  incompetence. 

Digestive  disturbances  also  cause  fimctional  cardiac  disturbances,  and 
in  small  and  weakly  infants  gastric  distention  may  so  embarrass  the 
heart  as  to  cause  death. 

It  is  difficult  to  write  in  any  precise  terms  concerning  the  influences 
on  the  heart  of  rapid  growth  and  development  about  the  time  of  puberty, 
but  these  tax  a  damaged  heart  and  predispose  to  a  breakdown  unless 
particular  care  is  bestowed  upon  children  at  that  age. 

Lastly,  there  are  mysterious  causes  of  heart  disease  which  are  met 
with  from  time  to  time.  The  best  example  is  a  curious  group  associ- 
ated with  an  enlarged  thymus.  These  cases,  fortunately  very  rare,  are 
highly  dangerous,  and  fatal  syncope  may  occur.  As  to  whether  the 
condition  of  the  thymus  has  any  causal  relation  to  the  cardiac  failure 
is  still  disputed,  but  the  association  of  the  two  rests  on  sound  clinical 
observation. 

Even  more  rare  are  cases  of  suprarenal  hemorrhage  in  infancy,  which 
may  lead  to  rapid  cardiac  failure  and  death.  This,  however,  is  men- 
tioned in  the  article  on  Diseases  of  the  Suprarenal,  q.  v. 


CONGENITAL  HEART  DISEASE. 

There  are  two  main  groups  of  congenital  heart  disease:  (1)  one  in 
which  malformation  occurs;  (2)  the  other  in  which  there  is  intra- 
uterine inflammation  of  the  valves,  with  secondary  defects  resulting 
therefrom  (Fig.  144.) 

1.  In  the  first  group  the  arrest  of  development  may  take  place  in  early 
fetal  life,  and  the  heart  only  consist  of  two  cavities,  a  ventricle  and 
auricle,  with  a  single  vessel  for  the  pulmonary  and  systemic  circulation. 
In  other  cases  there  are  two  auricles  and  one  ventricle. 

If  the  arrest  is  at  a  later  period,  then  the  septa  between  the  auricles 
and  ventricles  are  imperfect  aufl  the  aorta  and  pulmonary  artery  only 
partially  developed.     Or,  again,  the  large  vessels  may  be  displaced. 

In  the  later  period  of  fetal  life  it  is  sometimes  difficult  to  decide 
whether  the  imperfections  in  structure  are  due  to  disease  or  malforma- 
tion, and  thus  these  two  grouj)s  overlap  one  another,  })ut  it  is  in  these 
later  days  that  premature  closure  of  the  foramen  ovale,  or  premature 
obliteration  of  the  ductus  arteriosus  occurs. 


CONGENITAL  HEART  DISEASE 


689 


2.  The  second  group  is  of  more  interest;  here  are  found  those  very 
remarkable  cases  of  rheumatic  fetal  endocarditis  of  which  the  following, 
from  the  museum  catalogue  of  University  College  Hospital,  is  a  good 
instance : 

A  child,  who  lived  for  thirty  days,  was  discovered  the  day  after  birth 
to  have  a  loud  systolic  murmur,  heard  all  over  the  precordium  and  at 
the  back.  It  was  a  small,  quiet,  and  pale  infant,  but  except  for  occa- 
sional blueness  of  the  lower  eyelids  showed  no  cyanosis.  The  mother 
had  suffered  twice  from  rheumatic  fever,  and  was  attacked  a  third  time 
during  her  pregnancy.     Her  three  other  children  were  healthy. 

The  necropsy  showed  that  the  interventricular  septum  was  deficient 
at  the  upper  and  back  part,  and  to  the  margins  of  the  aperture  the  cusps 


Fig. 144 


Congenital  endocarditis  of  pulmonary  valve.    Congenital  heart  disease.    The  pulmonary  valve  is 
exposed  and  shows  endocarditis. 


of  the  mitral  and  one  cusp  of  the  tricuspid  valve  were  adherent.  Both 
valves  were  beaded  by  vegetations.  The  foramen  ovale  was  patent,  as 
also  the  ductus  arteriosus.     The  other  valves  were  natural. 

Another  striking  example,  which  came  under  my  own  observation, 
was  that  of  a  child  born  cyanosed  and  in  an  almost  asphyxiated  con- 
dition. Death  followed  on  the  third  day.  During  pregnancy  the  mother 
had  suffered  from  a  severe  attack  of  rheumatic  fever.  The  necropsy 
showed  extensive  and  recent  mitral  endocarditis. 

The  diagnosis  of  fetal  endocarditis  has  been  made  even  in  uterine 
life,  as  in  cases  reported  by  Peters  and  others. 

In  the  second  group,  then,  the  important  lesions  are  connected  with 
fetal  endocarditis  and  anomalies  of  the  valves  and  cardiac  septa. 
.   The  most  important  clinical  cases  in  this  group  are  those  in  which 
44 


690  DISEASES  OF   TlIK   HEART   ASD   BLOODVESSELS 

there  is  narr()win<r  of  the  piihnonarv  artery.  This  is  the  form  of  con- 
genital heart  disease  in  which  hfe  is  far  more  hkely  to  be  prolonged  to 
adnlt  age  than  in  any  other. 

There  is  fre(|uentiy  associated  with  this  stenosis  a  patent  inter- 
ventricular septum;  the  opening  is,  as  a  rule,  a  small  one  at  the  upper 
part  of  the  ventricular  septum,  in  the  meml)ranous,  undefended  space. 
In  addition,  the  foramen  ovale  may  be  patent  and  the  ductus  arteriosus 
incompletely  closed. 

Stenosis  of  the  aortic  or  mitral  valves  is  also  met  with  occasionally, 
but  the  reader  must  be  referretl  to  standard  works  upon  the  subject 
for  further  details. 

Symptomatology. — When  well  marked,  the  symptoms  of  congenital 
heart  disease  are  very  striking  ones,  and  when,  in  spite  of  them,  a  child 
survives  infancy,  his  appearance  is  often  so  characteristic  as  to  leave 
an  indelible  impression  on  the  memory.  It  is  simple  and  useful  to 
consider  the  symptoms  first  as  they  occur  in  infancy,  and  afterward 
as  they  occur  in  older  children.  This,  too,  is  justified  by  the  fact  that 
the  majority  of  cases  die  when  under  two  years  of  age. 

These  infants  are,  as  a  rule,  quiet  and  listless;  often  small  and  puny. 
The  nature  of  the  complaint  may  be  detected  at  once,  or  it  may  not 
show  itself  or  be  overlooked  for  some  months.  Cyanosis  is  the  symptom 
which  most  attracts  attention,  and  this  is  intensified  whenever  the 
infant  cries,  and  is  generally  detected  by  the  mother  or  nurse.  It  should 
be  borne  in  mind  that  cyanosis  is  not  always  present,  and  in  other  cases 
is  so  slight  as  to  escape  notice;  thus  it  is  not  unusual  for  the  medical 
attendant  to  discover  the  condition  of  the  heart  when  going  through 
a  routine  examination  of  the  child,  which  has  been  called  for  l)y  its 
failure  to  make  progress  and  by  its  general  feebleness.  This  cyanosis 
implicates  both  the  skin  and  mucous  membranes,  and  when  it  is  extreme 
reaches  a  mulberry  hue.  The  explanation  of  its  occurrence  has  not 
been  agreed  upon.  Some  have  attached  great  importance  to  venous 
congestion;  others  more  importance  to  deficient  aeration  of  the  blood. 
Of  late  a  good  deal  of  attention  has  been  directed  to  the  increase  in  the 
number  of  red  blood  corpuscles  which  have  been  found  in  these  con- 
ditions. This  is  not  peculiar  to  congenital  heart  disease,  but  it  is  some- 
times very  well  marked  in  such  cases,  and  wa,s  well  described  by  Toeni- 
essen.  A  case  examined  by  Baumholtzer  gave  the  following  result,  viz., 
red  blood  corpuscles,  9,447,000;  specific  gravity,  1071;  hemoglobin, 
160  per  cent.  Thus,  there  is  not  only  increase  in  the  number  of  red 
blood  corpuscles,  but  a  concentration  of  the  blood  itself,  which  tends 
to  make  its  passage  in  the  vessels  more  difficult. 

Cyanosis,  although  the  most  important,  because  the  most  frequent 
symptom — hence  the  name  morbus  ceruleus — is  by  no  means  the  only 
index  of  congenital  heart  disease.  In  addition  such  children  have  cold 
extremities,  and  in  some  cases  labored  respiration,  or  paroxysms  of 
disordered  breathing,  with  unconsciousness  and  epileptiform  attacks. 
These  cerebral  attacks  are  sometimes  prolonged  and  most  dangerous. 
In  other  cases  the  rapid  action  of  the  heart  may  attract  the  mother's 


CONGENITAL  HEART  DISEASE  691 

attention,  and  for  this  symptom  alone  a  child  may  be  brought  to  the 
doctor  and  a  congenital  malformation  discovered. 

Clubbing  of  the  fingers,  toes,  and  nose  is  not  so  frequent  as  cyanosis, 
but  whenever  there  is  any  suspicion  of  congenital  heart  disease  it  should 
be  looked  for.  It  may  occur  with  or  without  cyanosis,  but,  as  a  rule,  is 
rather  later  in  its  appearance. 

On  physical  examination  the  question  of  diagnosis  is  usually  settled. 
The  heart  is  found  slightly  enlarged,  especially  to  the  right  of  the 
sternum,  and  there  is  sometimes  bulging  of  the  precordial  region.  On 
auscultation  a  loud  systolic  murmur  is  audible  over  the  precordium, 
with  its  point  of  maximum  intensity  over  the  pulmonary  artery  imme- 
diately to  the  left  of  the  sternum.  This  bruit  is  harsh  and  dominates 
all  other  sounds,  and  is  by  far  the  most  important  sign  of  congenital 
heart  disease.  The  observer  may  be  struck  by  the  rapidity  of  the  action 
of  the  heart,  even  in  an  infant,  and  the  pulse  on  slight  exertion  becomes 
feeble  and  irregular.  Lastly,  a  fine  systolic  thrill  can  be  detected  by 
the  hand  placed  over  the  upper  part  of  the  chest. 

This  is  a  description  of  the  ordinary  bruit  of  moderate  pulmonary 
stenosis.  The  bruits,  however,  are  not  all  of  them  loud,  but  may  be 
soft  and  whiffing,  and  then  should  the  child  cry  they  are  easily  over- 
looked. In  such  cases  of  doubt  it  is  very  wise  to  insist  upon  more  than 
one  careful  examination  before  pinning  one's  self  to  a  definite  opinion. 

Cases  which  are  still  more  puzzling  are  those  in  which,  during  the 
first  few  weeks,  there  is  no  bruit,  although  there  are  the  symptoms  of 
congenital  heart  disease,  and  yet  which  later  develop  a  loud  bruit,  with 
a  diminution  in  the  urgency  of  the  symptoms.  The  bruit  is  not  always 
basal,  or  heard  at  its  loudest  at  the  base  of  the  heart  to  the  left  of  the 
sternum;  sometimes  there  is  an  apical  murmur,  and  in  other  cases  the 
murmur  may  be  diastolic.  Yet,  again,  another  bruit  may  cause  a  con- 
tinuous humming  sound  throughout  the  cardiac  cycle,  and  when  this 
is  heard  at  its  loudest  to  the  left  of  the  sternum  it  suggests  a  patent 
ductus  arteriosus.  The  second  sound,  then,  is  sometimes  noticed  to  be 
singularly  loud  and  clanging,  and  after  death  a  dilatation  of  this 
pervious  ductus  arteriosus  has  been  discovered.  Under  normal  cir- 
cumstances the  ductus  arteriosus  is  closed  within  the  first  fortnight 
of  life. 

The  lives  of  these  infants  are  very  precarious.  Sometimes  they  die 
quite  suddenly,  an  occurrence  which  is  so  alarming  and  distressing  that 
it  is  well  for  the  medical  attendant  to  bear  it  in  mind  when  treating  such 
cases.  The  temperature  is  often  low,  and  the  least  exposure  to  cold  may 
result  in  an  attack  of  bronchitis.  An  attack  of  gastroenteritis,  or  of 
measles,  or  any  other  infective  disease  may  prove  rapidly  fatal,  and  thus 
it  is  that  either  from  the  severity  of  the  cardiac  lesion  itself  or  from 
some  complication  superadded  to  it  many  cases  die  in  infancy.  Yet 
there  are  a  considerable  number  of  children  who  survive,  and  among 
them  are  found  the  most  classical  examples  of  congenital  heart  disease. 

Since  the  lesion  in  these  cases  is,  as  a  rule,  some  degree  of  pulmonary 
stenosis,  the  physician  will  probably  find  that,  in  addition  to  cyanosis 


(592  DISEASES  OF    THE  HEART   AXD   BLOnDVESSELS 

and  rlubbing  of  the  fingers,  there  are  a  cardiac  area  increased  \o  the 
riglit,  a  svstoHc  hruit  aiuHhle  in  tlie  second  interspace  to  the  left  of  the 
sternum,  a  faint  puhnonary  second  sound,  and  a  long  systolic  murmur, 
the  maxinunn  intensity  of  which  is  at  the  base. 

The  amount  of  hypertrophy  varies  considerably,  if  one  can  formulate 
any  general  rule;  it  is  that  the  enlargement  of  the  heart  is  often  surpris- 
inirlv  slij^ht.  Yet  there  are  undoubtedly  cases  in  which  the  breadth 
of  the  cardiac  dulness  is  extraordinarily  increased. 

A  very  interesting  result  in  some  cases  is  an  arrest  of  development. 
Two  cases  of  my  own,  both  of  them  little  girls,  exemplified  this  well, 
one  of  whom  resembled  a  doll;  her  features,  bones,  and  muscles  were  all 
small  and  delicate.  These  children  were  intelligent,  although  not  strong 
enouffh  to  undertake  any  sustained  mental  etiort.  There  are  other  cases 
in  which  the  intelligence  is  deficient,  and  a  special  allusion  must  be 
made  to  the  occurrence  of  the  Mongolian  type  of  imbecility  in  association 
with  congenital  heart  disease,  as  was  pointed  out  by  Garrod.  This  is 
a  very  serious  matter,  for  such  children  are  not  only  short-lived,  but, 
even  if  they  survive,  are  never  able  to  earn  a  living.  There  are  other 
cases  in  which  the  frame  is  not  stunted  by  this  contlition;  the  child  may 
be  both  stout  and  strongly  built.  The  older  children,  just  as  the  infants, 
feel  the  cold  very  much,  and  prefer  to  sit  hugging  the  fire,  for  exertion 
makes  them  short  of  breath.  One  such  patient  had  a  great  weakness 
for  drinking  hot  beer,  which  his  father,  who  kept  a  public  house,  pre- 
scribed for  him  on  his  own  responsibility.  Although  the  very  fact  that 
these  children  have  survived  infancy  is  proof  that  they  have  some 
vitality,  they  have  also  great  dangers  to  contend  against.  The  develop- 
ment of  the  body  with  the  commencement  of  j)uberty  throws  a  strain 
upon  them  and  tuberculosis  is  more  apt  to  attack  them  then,  or  later 
in  life,  than  before  puberty.  It  has  been  my  experience  to  find  that 
between  the  ages  of  two  and  twelve  an  attack  of  endocarditis  has  been 
the  most  fref|uent  cause  of  death,  but  of  the  importance  of  tubercu- 
losis there  can  be  no  doubt,  as  was  clearly  demonstrated  by  Peacock. 

The  tlevelopment  of  a  chronic  cough  and  a  history  of  wasting  will 
put  us  on  our  guard  against  tuberculosis,  but  no  hurried  conchision 
should  be  drawn.  The  naturally  ])lue  color  of  the  faces  of  these  children 
may  lead  to  an  exaggerated  idea  of  the  gravity  of  the  intercurrent 
pulmonary  disease,  and  the  medical  man  be  led  to  make  somewhat 
hastily  a  most  gloomy  prognosis. 

Other  respiratory  affections,  notably  bronchitis  and  pneumonia,  are 
serious  occurrences,  because  of  the  extra  strain  they  throw  u])on  the 
already  impaired  right  ventricle. 

The  development  of  endocarditis  is  a  very  important  complication 
and  by  no  means  easy  to  detect,  for  it  will  l)e  readily  understood  that 
with  a  loud  murmur  due  to  the  malformation  already  present,  one  of 
the  great  proofs  of  a  recent  endocarditis,  the  development  of  a  bruit, 
is  lial^le  to  be  obscured.  The  occurrence  is  most  serious,  for  the  endo- 
carditis is  usually  malignant  in  type. 

In  some  cases  it  is  an  evidence  of  an  attack  of  rheumatic  fever,  for 


CONGENITAL  HEART  DISEASE  693 

pericarditis  and  arthritis  may  occur  simultaneously;  in  others  the  cause 
is  obscure  and  spoken  of  as  infective.  The  fever  may  be  high  and 
irregular,  and  there  is  increased  dyspnea  and  precordial  pain.  The 
action  of  the  heart  is  much  excited,  and  generally  it  is  possible  to  get 
so  far  in  the  diagnosis  as  to  recognize  that  there  is  some  acute  compli- 
cation causing  these  serious  symptoms.  If  a  bruit  of  recent  origin,  and 
localized  to  some  other  valve,  can  be  detected,  as,  for  example,  an  aortic 
diastolic  murmur  or  a  mitral  systolic,  the  significance  is  very  great, 
and  this  will  be  the  most  reliable  direct  evidence. 

Pericarditis  and  other  manifestations  of  rheumatic  fever  are  also 
valuable  aids  in  determining  the  presence  of  acquired  disease. 

It  is  not  surprising  to  meet  with  this  complication,  for  it  is  recognized 
that  some  cases  of  congenital  heart  disease  are  due  to  intrauterine 
rheumatic  endocarditis,  and  the  recent  attack  is  but  an  exemplification 
of  the  well-known  tendency  of  rheumatic  children  to  be  again  and  again 
attacked  by  rheumatism. 

Another  danger  to  life  is  a  gradual  failure  of  compensation,  comparable 
to  the  failure  which  is  seen  so  often  in  acquired  heart  disease.  On  the 
whole,  this  is  less  common  than  perhaps  might  have  been  expected. 
The  right  ventricle  dilates  and  the  tricuspid  valve  becomes  incompetent, 
and  then  there  follow  the  usual  sequence  of  events — dropsy,  ascites, 
congestion  of  the  lungs,  engorgement  of  the  liver,  and  albuminuria. 
•  In  such  cases  it  is  sometimes  difficult  to  determine  whether  all  this 
has  not  been  really  the  result  of  acquired  and  not  congenital  heart 
disease.  When  there  is  no  very  definite  history  to  serve  as  a  guide, 
and  when  for  some  reason  or  other  the  upper  lobe  of  the  left  lung 
has  retracted  from  the  cardiac  area  and  exposed  the  pulmonary  artery, 
it  is  sometimes  most  difficult  to  decide  between  congenital  and  acquired 
disease,  for  a  hemic  pulmonary  murmur,  when  the  upper  lobe  of  the 
left  lung  is  thus  retracted,  may  be  so  greatly  intensified  as  to  very 
closely  resemble  a  congenital  bruit. 

Diagnosis. — This  is  not,  as  a  rule,  difficult,  and  when  difficulties 
arise  they  depend  either  upon  the  absence  of  cyanosis  or  of  a  reliable 
history. 

In  the  absence  of  cyanosis  the  condition  may  be  quite  overlooked, 
and  without  any  reliable  history  it  may  be  thought  that  the  disease  is 
acquired.  When  both  congenital  and  acquired  disease  of  the  valves 
are  present,  the  twofold  nature  of  the  lesions  may  not  be  recognized, 
although,  even  if  this  should  be  the  case,  this  may  prove  to  be  rather  of 
academic  than  practical  interest. 

Great  dilatation  and  hypertrophy  of  the  heart  suggest  acquired 
disease,  as  also  do  apical,  systolic,  and  diastolic  murmurs.  Cyanosis  may 
result  from  emphysema,  advanced  tuberculous  disease,  or  mediastinal 
growths,  but,  as  a  rule,  the  bruits  of  the  congenital  affection  prevent 
any  mistake.  Some  cretins  are  remarkably  cyanosed;  this  affects  the 
extremities,  and  on  more  than  one  occasion  I  have  heard  considerable 
doubt  expressed  as  to  whether  the  condition  of  cretinism  could  really 
explain  this  phenomenon.     In  such  cases  treatment  by  thyroid  extract 


694  DISEASES  OF   THE  HEART  AND  BLOODVESSELS 

has  settled  the  cjiiestion,  and  the  cyanosis  has  rapidly  disappeared  with 
the  improvement  in  the  eretinons  .sym])t()ms. 

The  details  of  the  difjercntial  diagnosis  of  the  various  forms  of  mal- 
formation are  beyond  the  scope  of  this  article,  and,  moreover,  unsatis- 
factorv.  We  may  go  hopelessly  wronfj  in  such  attempts,  and  find  after 
death  a  condition  utterly  difi'erent  fn)n>  that  which  had  been  surmised 
durinji;  life.  Some  of  the  main  indications  are  given  under  the  symptoms 
of  the  disease. 

Prognosis. — ^The  general  prognosis,  since  it  includes  every  sort  of 
malformation  compatible  with  live-birth,  is  grave.  The  first  principle 
is  to  reckon  sym})toms  as  more  important  than  physical  signs.  A  small 
opening  in  the  foramen  ovale  or  in  the  septum  between  the  ventricles 
may  give  rise  to  no  symptoms  at  all.  On  the  other  hand,  such  symptoms 
as  paroxysms  of  dyspnea,  or  convulsions,  or  a  persistent  low  temperature 
are  very  ill  omened. 

Anotlier  important  point  in  the  general  prognosis  is  the  social  status 
of  the  patient.  A  child  who  can  be  given  all  the  advantages  of  a  warm 
climate,  and  can  escape  in  after  years  the  not  unmixed  blessing  of 
having  to  earn  a  living;  who  can  be  well  clothed,  and  be  educated  by 
tutors,  stands  a  far  better  chance  than  the  child  who  sells  matches  in 
the  streets,  with  icy  cold  extremities  and  no  proper  meals. 

The  occurrence  of  an  attack  of  acute  rheumatism  is  an  exceedingly 
serious  matter,  and  liable  to  end  in  a  malignant  endocarditis.  Repeated 
bronchitis,  pneumonia,  tuberculosis,  and  all  acute  maladies,  including 
influenza,  may  entirely  alter  the  prognosis  in  a  case  apparently  favor- 
able. 

When  the  condition  of  the  heart  itself  is  taken  into  account,  the 
prognosis  is  bett(T  in  lesions  of  the  ordinary  type  tlian  when  the  lesion 
is  an  unusual  o\\(\  It  is  not  indeed  possible,  even  with  the  ordinary 
systolic  bruit  and  thrill,  to  be  absolutely  certain  of  the  nature  of  the 
malformation,  but  in  general  it  means  a  pulmonary  stenosis,  and  this, 
if  moderate  in  degree,  is  compatible  with  a  life  reaching  to  adult  years. 

Laurence  Humphry  points  out  that  the  prognosis  is  better  when 
with  pulmonary  stenosis  there  is  an  opening  in  the  ventricular  septum, 
for  this  opening  eases  the  pressure  in  the  right  ventricle. 

A  systolic  murmur  heard  at  its  maximum  intensity  about  the  middle 
of  the  precordial  area,  and  not  giving  rise  to  a  thrill  or  to  hypertrophy 
of  the  right  ventricle,  suggests  this  particular  lesion  of  a  patent  septimi 
ventriculorum. 

The  extent  of  the  cardiac  dulness  to  the  right  of  the  sternum  is  also 
some  guide,  for  when  the  increase  is  considerable,  either  the  lesion  is 
considerable,  or  the  strain  on  the  right  side  is  great  in  proportion  to 
the  extent  of  lesion. 

The  degree  of  cyanosis  cannot  be  relied  upon  in  the  cjuestion  of 
prognosis.  The  most  cyanosed  cases  that  I  have  met  with  have  been 
children  over  eight  years  of  age.  On  the  other  hand,  it  happens  by  no 
means  uncommonly  that  infants  with  congenital  heart  disease  and  little 
or  no  cyanosis  die  quite  suddenly.    The  only  warning  that  may  be  given 


RHEUMATIC  HEART  DISEASE  695 

in  such  cases  is  a  refusal  to  take  food  and  a  general  surface  coldness. 
Again,  it  does  not  follow  that  because  there  is  only  a  slight  degree  of 
cyanosis,  which  has  only  been  observed  when  the  child  began  to  walk, 
there  may  not  also  be  a  rapid  development  of  serious  symptoms  and 
death. 

Cyanosis,  in  its  most  marked  degree,  is  associated  with  such  lesions 
as  pulmonary  stenosis  and  patent  septa,  and  these  are  recognized  as 
the  less  severe  types  of  malformation. 

In  most  cases  a  fairly  accurate  idea  of  the  future  can  be  obtained  by 
keeping  in  mind  these  facts,  and  with  caution  the  parents  can  be  pre- 
pared to  see  the  true  meaning  of  such  a  serious  malformation.  For 
my  own  part,  I  am  not  a  believer  in  attempts  at  dramatic  prognosis, 
and  feel  that  to  assume  an  attitude  of  certainty,  where  there  is  so  much 
uncertainty,  is  only  to  tempt  fate.  To  say  "He  will  die  in  three  months," 
and  to  be  correct,  is,  at  best,  to  win  a  gloomy  triumph,  and  if  the  patient 
lives  as  many  years,  the  doctor  becomes  an  object  of  ridicule.  Some 
cases  live  on  to  thirty,  forty,  or  even  sixty  years  of  age. 

Treatment. — Treatment  is  palliative.  These  children  must  be  kept 
warm  and  very  carefully  clothed  with  this  in  view.  If  possible,  they 
should  always  live  in  a  warm  and  equable  climate.  I  prefer  to  give 
them  an  excess  of  fat,  if  they  can  digest  it,  and  I  also  attempt  to  keep 
them  fat.  Whenever  possible,  they  should  be  educated,  but  no  mental 
strain  should  be  permitted.  In  the  event  of  their  living,  their  employ- 
ment must  be  light,  and  they  should  have  plenty  of  sun  and  fresh  air. 
The  exercise  allowed  must  be  adapted  to  each  particular  case,  and  will 
always  need  caution.  Cod-liver  oil  with  iron  or  malt  are  useful  pre- 
scriptions. Digitalis  is  not  so  useful  as  strychnine  as  a  cardiac  stimulant. 
When  there  is  an  attack  of  heart-failure  with  great  lividity  the  application 
of  leeches  is  indicated  to  relieve  the  veins  of  blood.  For  the  fainting 
attacks  I  have  often  foimd  exceedingly  useful  a  prescription  of  sal 
volatile  (carbonate  of  ammonium),  ether  and  peppermint. 

The  general  rules  for  the  treatment  of  acquired  heart  disease  are 
equally  applicable  to  this  affection. 


RHEUMATIC  HEART  DISEASE,  INCLUDING  THE  HEART 
DISEASE  OF  CHOREA. 

Acute  rheumatism  is  the  most  frequent  cause  of  heart  disease  in 
childhood,  at  which  time  it  is  more  liable  to  damage  the  heart  than 
later  in  life.  Durine;  the  first  three  or  four  vears  of  life,  however,  rheu- 
matic  fever  and  the  consequent  heart  disease  are  rare.  The  explanation 
of  this,  so  far  as  the  poor  are  concerned,  lies  probably  in  the  fact  that 
the  very  young  have  not  the  same  amount  of  exposure  to  cold  and  wet; 
nor  is  there  the  influence  of  school  life,  with  its  crowded  rooms,  foul 
air,  and  journeys  to  and  fro,  often  made  on  a  stomach  not  too  well 
filled. 

The  incidence  rises  steadily  from  four  years  of  age,  and  about  ten 


696  DISEASES  OF   THE  HEART  AXD  BLOODVESSELS 

reaches  its  niaxiimim,  though  for  some  years  after  it  is  frequent  enough. 
As  rheumatism  is  most  rife  in  spring  and  autumn,  so,  too,  the  frequency 
of  this  form  of  heart  disease  rises  at  those  times;  there  is  also  a  greater 
tendency  to  heart  affections  in  some  years  tlian  in  others. 

Statistics  ;u^  to  the  rehitive  frequency  of  its  oci-urrence  in  rheumatism 
have  now,  I  think,  served  their  purpose,  and  liave  shown  that  every 
case  of  rheumatism  in  chihlhood  should  he  looked  upon  as  a  probable 
ease  of  heart  disease. 

In  regard  to  the  iuHuence  of  hereility  it  has  long  been  atlmittcil  that 
there  is  a  family  tendency  to  heart  atlections,  as  there  is  also  to  renal 
or  nervous  ones.  So  far  as  this  form  is  concerned  it  is  explained  by  the 
fact  that  the  rheumatic  predisposition  is  strongly  hereditary.  The 
heart  ilisease  is,  in  my  opinion,  a  direct  effect  of  the  rheumatic  infec- 
tion ami  not  a  complication  dependent  upon  some  secondary  process. 

To  me,  then,  rheumatic  heart  tlisease  is  a  direct  consequence  of  the 
access  of  the  infective  agent  of  rheumatism  to  the  cardiac  valves,  the 
pericardium,  and  the  heart  wall  through  the  channels  of  the  coronary 
bloodvessels.  The  lesions  are  the  results  of  the  poisons  of  the  bacteria, 
and  of  the  vital  reaction  of  the  tissues  to  those  poisons.  These  lesions, 
I  further  hold,  are  specific  lesions,  though  the  reatler  should  clearly 
understantl  that  there  are  many  who  would  dissent  from  this;  ami 
although  in  agreement  up  to  that  point  would  here  differ,  and  hold 
that  manv  different  infections  may  cause  rheumatic  fever,  and,  there- 
fore, rheumatic  heart  disease. 

In  addition  to  the  causes  already  mentioned,  namely,  age,  heredity, 
and  the  season  of  the  year,  there  can  be  little  doubt,  I  think,  that  a  cold, 
inclement  climate,  a  clay  soil,  and  damj^  houses  are  also  factors,  and 
must  be  taken  into  account.  Overcrowding  and  malsanitation  would 
also  appear  important,  for  rheumatic  heart  disease  is  especially  common 
in  large  towns.  The  path  of  infection,  so  often  by  way  of  the  tonsils, 
points  also  to  the  congregation  of  children  in  schools  as  a  factor. 

It  is,  I  believe,  an  important  matter  to  reconsider  the  predisposing 
causes  of  rheumatic  heart  disease  by  the  light  of  the  infective  nature  of 
rheumatism,  and  I  trust  that  the  medical  profession  will  soon  make 
some  great  effort  in  this  direction  on  behalf  of  the  children  of  the  poor. 
Personally,  I  attach  no  importance  to  tliet,  beyonil  considering  that  any 
gross  error,  such  as  giving  large  quantities  of  meat  to  the  young,  is 
detrimental  to  their  general  health. 

As  rheinnatic  heart  disease  is  the  most  frequent  and  most  important 
of  all  heart  affections,  and  one  of  the  most  important  subjects  in  chil- 
dren's diseases,  it  will  be  made  in  this  article  the  pivot  upon  which  a 
description  of  all  the  other  acquired  forms  will  turn,  for  the  same  general 
principles  apply  to  all  the  forms  of  heart  disease. 

Pathology.  General  Outline. —  Rheumatic  fever  damages  endo- 
cardium, myocardium,  and  pericardium,  and  to  this  general  injury  is 
given  the  name  corditis.  "While  recognizing  this  tendency  to  a  general 
damage,  it  is  also  clear  that  in  some  cases  the  stress  falls  upon  one 
structure  more  than  another.    Thus  the  valves  are  the  most  frequently 


RHEUMATIC  HEART  DISEASE  697 

injured,  and  of  these  especially  the  mitral.  This  is  probably  because 
it  is  the  most  elaborate,  and  the  best  supplied  with  blood,  and  I  would 
compare  it,  for  this  reason,  to  a  large  joint. 

The  first  step  in  the  morbid  process  is  the  deposition  of  the  micro- 
coccus in  the  subendothelial  layer  of  the  fibrous  tissue  of  the  valve  or 
pericardium.  Then  follow  swelling  of  the  connective  tissue,  dilatation 
and  even  rupture  of  blood  capillaries,  and  exudation.  If  the  process 
is  severe,  the  connective  tissue  is  destroyed  and  becomes  necrotic,  and 
the  lining  endothelium  which  lies  over  the  damaged  area  of  valve  or 
pericardium  is  also  injured.  In  the  mean  time  the  protective  processes 
come  into  action.    The  connective-tissue  cells  multiply,  and  the  leuko- 

FiG. 145 


/ 

d.^^^,^ 

Vy 

^ 

, 

••  *  ^.      ^        •                            '..                     .          .•       . 

y 

•\-      ^'\      •    "■\.                       .                  t     .     .    ^ 

-^            ''     ^\ 

^X'i      ^'-                            "'-    U 

'  '    •^'■■4 

. .  --<<-:'  T"-  ^  <..  ^  ^^  -^^%s«-^^^ 

^^iT--^ 

\Valve 

Kheurnatic  endocarditis,  showing  granulation  in  the  necrotic  stage. 

cytes,  escaping  from  the  bloodvessels,  take  up  the  bacteria.  The  endo- 
thelium, where  it  is  not  fatally  injured,  does  the  same  duty,  and,  event- 
ually, a  balance  is  usually  struck  between  the  disease  and  the  reaction. 
The^  bacteria  are  destroyed,  but  the  tissues,  on  the  other  hand,  are  often 
irreparably  damaged,  and  need  to  be  patched  with  scar  tissue.  This 
sequence  of  events,  the  march  of  the  disease,  the  march  of  the 
resistance,  the  struggle  and  imperfect  victory,  is  the  history  of  active 
rheumatic  heart  disease  as  generally  met  with  in  childhood. 

The  cardinal  variations  from  this  type  are  two.  One  of  these  is  a 
continuous  smouldering  inflammation  in  which  the  entire  thickness  of 
the  valve  or  pericardium  is  implicated,  and  the  connective  tissue  through- 
out them  is  swollen  and  infiltrated  with  leukocytes.     This  process  is 


698 


DISEASES  OF  THE  HEART  AND  BLOODVESSELS 


very  slow,  but,  eventually,  there  is  ^reat  damage  to  the  connective 
tissue,  and  the  contraction  which  results  is  extreme.  It  is  well  ex- 
emplified by  the  true  mitral  stenosis,  'i'he  other  deviation  from  the 
ordinary  type  is  a  far  more  virulent  ])rocess,  in  which  the  balance 
between  the  disease  and  resistance,  far  from  being  equal,  is  greatly  in 
favor  of  the  disease,  and  the  bacteria  multiply  in  the  local  lesions  with 
great  rapidity.  It  is  well  exemplified  by  the  rheumatic  form  of  malignant 
endocarditis.  The  result  is  a  remarkable  one.  Large  vegetations  form 
upon  the  valve,  and  the  micro-organisms  are  scattered  by  the  blood 
stream  in  every  direction.  Here,  again,  it  must  be  pointed  out  that 
many  will  not  accept  this  interpretation,  but  maintain  that  all  cases 


Fig. 146 


Rheumatic  endocarditis,  showing  diplococci. 


of  malignant  endocarditis  are  the  result  of  mixed  infections  with  septic 
micro-organisms.     (See  Plate  XX.,  Figs.  145,  14(),  147  and  148.) 

Endocarditis.  The  cardiac  valves  are  damaged  in  this  order  of 
frequency:  (1)  the  mitral,  (2)  the  aortic,  (3)  the  tricuspid,  and,  very 
rarely,  (4)  the  pulmonary.  I  am  convinced  that  the  statement  that 
rheumatism  only  affects  the  left  side  of  the  heart,  because  the  blootl 
there  is  arterial,  is  one  of  those  ideas  which  appeals  rather  to  the 
imagination  than  to  the  reason.  The  mitral  and  aortic  valves  are 
affected  simultaneously  or  in  rapid  sequence  with  considerable  fre- 
quencv,  but  anv  severe  affection  of  the  tricuspid  valve  is  very  rare. 

The  local  lesions  in  the  mitral  valve  take  the  form  of  small,  pinhead 
vegetations  ranged  along  the  lines  of  contact  of  the  segments,  and  they 
are   usually  situated   upon   the   auricular  surfaces   of  the   mitral   and 


PLATE  XX. 


Rheumatic  Endocarditis,  showing   the  Commencement  of  a 

Vegetation. 

A  section  through  a  cusp  of  the  pulmonary  valve.      (Herman).     All  the 
valves  -were  damaged  by  rheumatism. 
A.     The  early  vegetation  formed  by  broken  connective  tissue. 
-B.     Endothelial  lining  of  upper  surface  of  valve. 

C.  Conneetiv3  tissue  framework  of  valve. 

D.  Endothelial  lining  of  under  surface  of  valve. 


RHEUMATIC  HEART  DISEASE 


699 


tricuspid  valves  and  the  ventricular  aspect  of  the  aortic  valves  (see 
Fig.  149),  but  in  severe  cases,  especially  of  the  malignant  type,  they  are 
met  with  on  both  aspects,  on  the  chordae  tendinese,  on  the  inner  surface 
of  the  walls  of  the  heart  itself,  and  at  the  base  of  the  aorta  (Fig.  153). 
The  various  stages  in  the  production  of  the  lesion  are  seen  in  Plate 
XX.,  and  Figs.  145  and  146. 

The  edge  of  the  valve  in  the  earliest  stage  is  reddened,  in  the  later 
stages,  the  vegetations  have  a  waxy  yellow  appearance,  and  in  some 
malignant  cases  these  vegetations  reach  a  large  size.  If  the  reader  will 
turn  to  Fig.  145  he  will  see  that  in  the  necrotic  tissue  there  are  no  micro- 


FiG. 147 


Malignant  endocarditis.    Rheumatic.    Showing  masses  of  diplococci  in  the  necrotic  tissue 

of  the  vegetation. 


organisms,  while  in  Fig.  147  they  are  numerous.  The  former  is  an 
instance  of  the  usual  simple  endocarditis  and  the  latter  of  the  malignant 
type.  This  is  the  secret  of  their  difference,  and  brings  home  very 
vividly  the  great  clinical  fact  that  simple  acute  rheumatic  endocarditis 
is  never  fatal  in  the  acute  phase.  Why  should  it  be?  The  micro- 
organisms are  destroyed,  the  valve  heals,  and  the  acute  stage  is  very 
often  over  even  when  the  patient  succumbs  to  pericarditis.  Cultures 
from  such  valves  are  generally  negative.  But  it  is  far  otherwise  with 
malignant  endocarditis — a  veritable  bacterial  volcano — for  that  disease 
is  usually  fatal  (Fig.  147). 


700  DISEASES  OF   THE  HEART  AND  BLOODVESSELS 

When  the  process  of  heaHng  is  studied,  two  types  of  jijreat  practical 
importance  can  be  recognized.  The  first  is  that  in  which  the  free  edge 
of  the  valve  is  contracted  and  crumpled  In-  scarring,  and  its  edge  thick 
and  uneven;  it  is  the  result  of  the  bursting  out  of  the  vegetations 
along  the  edge  of  the  valve.    The  result  of  such  a  lesion  is  incompetence. 

The  other  is  re])resented  by  a  welding  together  of  the  segments  of 
the  valve,  a  shortening  of  the  chonhe,  and  a  general  thickening  of  the 
valvular  ring.  It  is  the  outcome  of  a  chronic  smouldering  inflammation 
which  affects  the  entire  thickness  rather  than  the  margin  of  the  valve. 
The  result  is  a  stenosis  in  which  the  opening,  which  may  only  admit  the 
top  of  a  ])encil,  may  be  slit-like,  or  may  kccj)  its  circular  outline,  and 
then  resemble  the  orifice  at  the  base  of  a  funnel. 

Fig. 148 


A 
liheumatic  pericarditis.    Section  through  visceral  layer,  showing  the diplococci ;  A,  cardiac  muscle ; 
B,  visceral  pericardium ;  C,  diplococci ;  D,  connective-tissue  cells  ;  E,  inflammatory  cell. 

There  are  connecting  links  between  these  two  great  types  of  heal- 
ing, but  in  their  pure  forms  they  represent  the  two  different  processes 
alluded  to  above.  The  aortic  valves  are  seldom  very  gn^atly  damaged, 
and  in  most  cases  a  slight  thickening  and  crumpling  are  the  results 
of  the  inflammation.  The  tricuspid  valve  is  infected  more  frequently 
than  is  generally  known,  but  usually  only  to  a  slight  and  practically 
insignificant  extent,  yet  there  are  occasional  examples  in  which  it  is 
greatly  damaged,  and  there  may  in  these  cases  result  in  later  life  a 
combined  mitral  and  tricuspid  stenosis. 

The  pulmonary  valve  is  damaged  so  rarely  and  so  slightly  as  to  need 
no  further  comment. 


RHEUMATIC  HEART  DISEASE 


701 


The  Pericardium. — Pericarditis  is  the  result  of  the  more  severe  types 
of  rheumatic  fever,  and  may  be  a  cause  of  death. 

In  very  acute  cases  the  pericardium  is  reddened,  and  there  is  a 
moderate  amount  of  exuded  fluid  in  the  sac  which  is  turbid  or  even 
blood-stained.  In  other  cases,  of  longer  duration,  there  is  much  fibrino- 
cellular  exudation  (Fig.  152)  which  adheres  to  both  layers  of  the  peri- 
cardium. With  this  there  are  also  flakes  of  exudation  lying  free  in  the 
cavity,  and  the  fluid  is  more  opaque. 

In  still  other  cases  there  has  been  an  attempt  at  recovery  and  the 
two  layers  are  found  adherent  with  recent  plastic  exudation,  and, 
finally,  the  evidence  of  an  old  pericarditis  may  be  discovered  by  the 


Fig. 149 


Simple  rheumatic  miiral  endocarditis.     To  show  the  Une  of  vegetation  upon  the  auricular 
surface  of  the  mitral  valve. 


occurrence  of  partial  or  total  adhesion  of  the  two  layers  by  connective- 
tissue  formation. 

The  actual  morbid  processes  in  pericarditis  start  in  the  subendothehal 
lavers  of  the  pericardium,  and  it  is  even  then  general,  essentially  the 
result  of  numerous  individual  foci  of  inflammation  originated  by  the 
infective  agent. 

The  yellow  liquid  pus  seen  in  suppurative  pericarditis  is  not  found  in 
true  rheumatic  cases. 

If  the  pericardium  is  found  to  be  adherent  it  is  important  to  recognize 
the  extent  to  which  this  has  occurred.    Is  it  simply  an  adhesion  of  the 


702 


DISEASES  OF   THE  HEART  AXD  BLOODVESSELS 


two  layers,  or  in  addition  are  there  extensive  pleuropericarditis  and 
mediastinitis  chaining  the  heart  to  the  chest  wall  and  to  the  InngsV 
In  snch  cases  not  only  the  internal  endothelial  snrface  of  the  parietal 
pericardium  has  been  much  injured,  hut  the  inflammation  has  spread 
to  the  cellular  tissues  external  to  the  pericardium.  Finally,  a  large 
pericardial  exudation  is  rare  in  rheumatic  pericarditis,  and  it  is  from 
the  exudation  when  it  is  fibrinoplastic  that  the  diplococcus  can  be  most 
easily  isolated. 

The  Myocardium  is  frequently  damaged,  but  since  the  cardiac  wall 
consists  in  great  part  of  very  special  tissues — the  muscles  and  nerves — 
in  order  to  griisp  the  true  meaning  of  the  changes  the  word  myocarditis 


Fio. 150 


Rheumatic  carditis.    Fatty  change  in  cardiac  muscle :  A,  tatty  granules  ;  B,  fatty  granules  in 
horizontal  section  ;  C,  hyaline  change ;  D,  bloodvessel. 


is  better  set  aside.  In  place  of  thLs,  two  processes  will  be  considered: 
the  first,  which  damages  the  muscle,  a  subtle  bacterial  poison;  the 
second,  that  which  sets  up  inflammation  in  the  region  of  the  blood- 
vessels and  supporting  connective  tissue. 

It  would  be  wrong  to  attribute  such  a  change  as  the  fatty  degeneration 
of  the  muscle  entirely  to  a  slow  disturbance  of  nutrition  resulting  from 
damage  to  the  bloodvessels,  and  thus  make  it  dependent  upon  the 
inflammatory  changes;  for  intravenous  inoculation  of  a  monkey  with 
the  diplococcus  has  produced  these  fatty  changes  within  as  short  a  time 
as  four  days. 

The  morbid  processes  in  the  muscle,  which  are  of  the  greatest  practical 


RHEUMATIC  HEART  DISEASE 


703 


moment,  have  not  yet  been  thoroughly 
worked  out,  for  we  do  not  yet  know 
what  governs  their  frequency  or  severity, 
though  we  thoroughly  realize  their  exist- 
ence. There  is  no  doubt  that  they  are 
far  more  extensive  in  some  cases  than  in 
others,  and  as  the  outcome  of  an  exami- 
nation of  some  40  cases  of  rheumatic 
carditis,  it  seems  to  me  that  severe  injury 
is  especially  found  in  cases  of  virulent 
pericarditis.  But  this  injury  does  not 
spread  inward  from  the  pericardium,  for 
such  lesions  are  to  be  found  distributed 
in  patches  in  the  neighborhood  of  the 
small  bloodvessels  throughout  the  wall 
of  the  ventricles  (Fig.  150),  and  what  is 
still  more  convincing  may  be  found  with- 
out any  pericarditis.  It  is  only  to  be 
expected  that  the  morbid  changes  will  be 
most  evident  immediately  under  the  in- 
flamed pericardium,  for  the  diplococcus 
is  deposited  in  the  subendothelial  tissues, 
but  that  the  injury  spreads  from  the 
valvular  ring  or  pericardium,  as  a  drop 
of  ink  spreads  on  blotting  paper,  is  not 
correct. 

The  most  definite  alterations  in  the 
muscle  are  the  fatty  ones  as  shown  in 
Fig.  150.  Nuclear  changes,  fragmentation 
of  the  fibres,  diminished  and  exaggerated 
striation  have  also  been  observed.  The 
minute  bloodvessels  in  the  supporting 
connective  tissue  are  sometimes  ruptured 
and  minute  extravasations  result.  There 
is  also  perivascular  exudation,  and  in 
some  chronic  cases  there  are  found  in- 
terstitial and  perivascular  fibrosis.  The 
papillary  muscles  are  sometimes  very 
much  injured  by  the  poisons,  especially 
when  there  is  endocarditis ;  their  function 
is  thereby  impaired. 

In  cases  of  heart  disease  with  marked 
hypertrophy  the  muscular  fibres  are  not 
only  more  numerous,  but  larger  than 
normal. 

Symptomatology.  Early  Warnings. — 
Upon  these  early  warnings  I  would  lay 
the  greatest  stress,  for,  so  far  as  one  can 


Fig.  151 


CUHVJ')  3aniva3<aw3l 


704  DISEASES  OF   THE  HEART  AND  BLOODVESSELS 

see,  there  is  no  possible  cure  for  severe  organic  heart  cUsease  and  the 
great  hope  lies  in  its  prevention. 

In  all  cases  of  rheumatic  fever,  however  slight  or  doubtful,  it  must 
be  surmised  that  the  heart  is  damaged  until  it  is  certain  from  careful 
examination  that  it  has  escaped,  hy  rheumatic  fever  I  do  not  mean 
merely  articular  rheumatism,  but  all  the  varied  manifestations  of  the 
disease,  such  as  chorea,  myalgia,  erythema  nndtiforme,  nodule  forma- 
tion, bronchopneumonia  and  pleurisy,  arthritis  and  tonsillitis.  Any  of 
these  manifestations  are  warnings,  and  the  more  important  because  the 
early  heart  disease  of  childhood  is  notoriously  destitute  of  striking 
clinical  symptoms.  I  have  in  mind  a  child  whose  mother  remarked  to 
me  that  he  ran  about  "almost  like  other  children,"  yet  to  my  knowledge 
he  had  a  pericardium  adherent  from  a  previous  and  severe  pericarditis, 
and  disease  of  both  the  aortic  and  mitral  valves.  This  is  an  exj)erience 
common  to  all  who  are  acquainted  with  cardiac  disease  in  childhood. 

There  are  still  earlier  warnings  than  these  recognized  manifestations, 
some  of  which  must  be  equivocal,  yet  in  a  child  of  rheumatic  stock 
they  should  arouse  suspicion.  Wasting,  slight  fever,  vague  pains,  esj)e- 
cially  in  the  epigastrium,  nervousness  and  night  terrors,  anemia  and 
epistaxis  are  among  them,  and  though  no  one  would  pretend  to  be 
confident  that  rheumatic  fever  was  their  explanation,  experience  has 
shown  that  such  vague  symptoms  may  terminate  in  undoubted  cardiac 
rheumatism. 

It  is  the  many  manifestations  and  insidious  course  of  rheumatic  fever 
in  the  young  which  distracts  the  attention  from  the  heart  and  leads  to 
lamentable  oversights.  On  the  other  hand,  the  heart  may  be  the  first 
organ  severely  attacked,  and  there  are  nunuTous  cases  in  whicli  the 
symptoms  comjjel  our  attention  to  it.  Thus  the  child  complains  of 
pain  over  the  heart  and  shortness  of  breath,  or  the  mother  may 
notice  the  thumping  excited  impulse. 

Acute  Dilatation  of  the  Heart. — From  what  has  been  already 
written  concerning  the  morbid  anatomy,  it  will  be  readily  understood 
that  severe  rheumatic  infections  damage  all  parts  of  the  heart  and  cause 
a  carditis,  but  many  cases,  whether  acute  or  subacute,  need  not  neces- 
sarily be  severe,  and,  even  if  they  are  severe,  the  attack  must  have 
a  beginning,  and  that  beginning  usually  manifests  itself  as  acufe 
dilataiion  nf  the  heart.  From  this  there  may  be  comj)lete  recovery.  If 
these  patients  could  always  be  brought  under  medical  observation  at 
this  stage  it  seems  probable  they  might  be  saved  from  many  dangers. 
Unfortunately,  this  often  does  not  occur;  moreover,  in  some  cases  the 
dilatation  is  overlooked. 

The  ni/tnptoin.s  ol)served  in  dilatation  are  as  follows:  There  is  a 
slight  rise  of  temperature  (99.5°  F.).  The  child  may  be  a  little  short 
of  breath  and  pale.  The  rate  of  the  pulse  may  be  increased  to  90 
or  100,  and  be  irregular  in  rhythm  and  low  in  tension.  The  cardiac 
impulse  is  diffuse  and  the  area  of  deep  cardiac  dulness  increased  to 
the  left.  The  first  sound  in  the  region  of  the  impulse  is  short,  and 
at  the  base  the  second  sound  over  the  pulmonary  area  accentuated. 


RHEUMATIC   HEART  DISEASE  705 

There    may  also  be    a   soft,   systolic,    whiffing   murmur,  heard    most 
distinctly  internal  to  the  nipple  line. 

It  is  a  valuable  education,  although  it  needs  some  expenditure  of 
time,  to  ascertain  the  limits  of  the  deep  cardiac  dulness,  and  to  mark 
them  upon  the  chest  wall  with  an  aniline  pencil.  In  this  outline  three 
landmarks  should  be  also  indicated,  the  left  nipple,  the  midsternal  hne, 
and  the  subcostal  angle;  the  chart  can  then  be  traced  from  the  chest 
wall  upon  surveyors'  paper  and  kept  for  future  reference. 

Experience  has  amply  shown  that  this  stage  of  dilatation  mav  often 
be  demonstrated  before  any  severe  cardiac  lesion  has  occurred  and  that 
the  latter  may  subsecjuently  follow.  "Whether  in  any  particular  case 
its  detection  and  treatment  may  have  assisted  in  warding  off  the  graver 
lesions,  it  is  naturally  impossible  to  assert,  but  there  is  good  reason,  in 
\ievi-  of  the  value  of  rest  in  rheumatic  heart  disease,  to  hope  that  this 
has  happened. 

There  is  a  certain  danger  of  overcaution,  I  admit;  but  I  feel  so 
strongly  upon  the  value  of  this  early  sign  of  disease  that  if  this  article 
should  help  to  impress  the  importance  of  acute  dilatation  upon  the 
minds  of  those  who  are  not  alive  to  its  value,  it  will  have  done  some 
service  to  children. 

This  condition  of  dilatation  occurs  in  all  cases  of  rheumatic  carditis; 
it  complicates  the  valvular  lesions  and  pericarditis,  and  is  the  great 
cause  of  cardiac  failure  in  a  heart  already  damaged  by  former  attacks. 

When  the  dilatation  is  more  severe,  all  the  signs  mentioned  above 
will  l3e  emphasized,  and,  further,  the  systolic  murmur  can  then  be  traced 
outward  beyond  the  left  nipple.  Yet  even  from  severe  dilatation  there 
may  be  complete  recovery. 

How  is  it  known  that  with  this  acute  dilatation  there  is  not  mitral 
endocarditis?  In  man  and  in  animals  there  are  examples  on  record  of 
death  from  acute  rheumatic  dilatation  without  endocarditis.  If,  then, 
dilatation  can  reach  this  pitch  without  endocarditis,  it  is  legitimate  to 
argue,  in  view  of  the  complete  recovery,  that  the  less  severe  condition 
may  also  occur  and  with  greater  frecjuency.  Even  if  there  should  be 
a  slight  degree  of  endocarditis,  that,  in  itself,  would  not  account  for 
the  dilatation. 

ExDOC.iEDiTis. — Almost  insensibly  upon  this  early  dilatation  there 
may  follow  definite  endocarditis,  while  in  many  cases,  doubtless,  the  two 
processes  occur  simultaneously. 

The  symptoms  are  quite  unobtrusive,  a  little  palpitation,  some  vague 
pains  over  the  chest  and  epigastrium,  pallor  and  a  little  fever  are  the 
usual  ones.  The  temperature  may  run  up  a  degree  or  two.  Attentive 
observation  of  the  character  of  the  first  sound  at  the  impulse  and  of 
the  second  sound  at  the  aortic  area  will  be  needed.  In  mitral  endo- 
carditis the  first  sound  becomes  short  and  ill-defined,  and  then  a  soft 
systolic  murmur  appears  which  will  replace  it  to  a  greater  or  less  degree. 
Auscultation  should  be  practised  T\-ith  the  child  in  the  recumbent 
position  as  well  as  sitting  up,  and  both  external  and  internal  to  the  left 
nipple  line.  The  bruit,  at  first  perhaps  only  to  be  heard  occasionally, 
45 


706  DISEASES  OF   THE   HE  ART   A.\D   BLODDV  ESSEES 

becomes  later  pernuuient  and  often  enough  takes  on  a  to-and-fro 
eharaeter.  Such  a  to-and-fro  murmur  in  an  adult  might  suggest  the 
presence  of  double  aortic  disea.se,  but  in  the  child  it  is  evidence  of 
mitral  disease. 

The  diastolic  element  in  this,  however,  by  no  means  proves  the 
existence  of  mitral  stenosis;  for  in  many  fatal  cases  in  which  this  murmur 
has  been  noted  at  the  postmortem  examiiuition,  incompetence  only  has 
been  found.  Frequently  the  systolic  bruit  is  loud,  blowing,  prolonged, 
and  musical. 

Another  point  is  the  occurrence  of  a  curious  double  sound,  as  if  there 
was  reduplication  of  the  second  sound  of  the  heart.  The  whispering  of 
luf-tut-tut  perhaps  gives  the  impression  that  is  conveyed  to  the  ear. 
This  is  an  important  physical  sign,  and  implies  that  tlie  mitral  valve  is 
thickened,  and  has  been  the  seat  of  actual  inflammation. 

The  history  of  early  aortic  endocarditis  is  very  similar  to  that  of 
mitral  endocarditis,  but  needs  even  closer  observation. 

The  aortic  secontl  sound  becomes  faint  and  for  a  day  or  so  ])erhaps 
inaudible ;  then  there  appears  a  faint  systolic  bruit,  and,  lastly,  a  diastolic. 
This  latter  murmur  is  frequently  heard  better  to  the  left  of  the  sternal 
line,  or  behind  the  sternum,  or  even  in  the  tricuspid  area  than  over 
the  aortic  cartilage. 

Within  a  fortnight  the  collapsing  pulse  of  aortic  regurgitation  may 
l)e  (juite  definite,  and  already  the  radial  artery  may  have  increased 
in  calibre. 

The  tricuspid  valve  does  not  often  show  signs  of  injury,  though  when 
such  is  the  case  the  same  secjuence  of  events  will  be  noticed  as  in  the 
case  of  the  mitral  valve. 

Thus,  in  this  quiet  and  insidious  way  is  a  life  ruined  by  rheumatic 
heart  disease,  and  the  vital  importance  of  the  early  dilatation  l)rought 
home  to  us. 

Pericarditis. — It  is  in  the  severe  cases  of  rheumatic  fever  that  peri- 
carditis occurs  in  a  first  attack,  and,  moreover,  it  is  the  most  fatal  lesion. 
But,  in  spite  of  this,  I  would  warn  the  practitioner  of  the  danger  of 
supposing  that  a  heart  is  not  greatly  damaged  l)ecause  there  has  been 
no  pericarditis  or,  on  the  other  hand,  of  thinking  that  because  there 
has  been  pericarditis  the  damage  is  irreparable.  There  are  a  good 
many  cases  in  which  there  is  endocarditis  with  disease  of  the  myo- 
cardium, and  in  which  the  action  of  the  heart  is  very  excited,  yet  there 
is  not  pericarditis.  So  far  as  a  good  recovery  is  concerned  such  cases 
are  ill-omened.  On  the  other  hand,  a  fleeting  pericarditis  may  leave 
the  heart  but  very  little  the  worse  for  the  attack. 

With  the  onset  of  pericarditis  these  definite  symptoms  are  usually 
noticed.  The  temperature  rises  to  100°  or  101°  F.,  or  even  higher; 
there  is  pain  over  the  heart  and  increase  in  the  rate  of  respiration. 
The  child  is  pale  and  distressed,  sometimes  even  delirious,  and  the 
action  of  the  heart  excited.  The  pulse  fretjuency  increases  to  100  to 
120  or  more,  and  the  tension  is  low  and  the  rhythm  sometimes  irregular. 
The  important  clinical  sign  that  clinches  the  diagnosis  is  the  pericardial 


RHEUMATIC  HEART  DISEASE  707 

friction  rub.  It  is  a  physical  sign  of  the  utmost  vahie,  and  the  most 
careful  study  at  the  bedside  is  needed  to  recognize  its  different  characters. 

Pericardial  friction  is  usually  heard,  at  one  time  or  another,  in  the 
course  of  rheumatic  pericarditis,  and,  on  this  account,  rheumatic  peri- 
carditis is  an  easier  condition  to  diagnose  than  suppurative  pericarditis, 
in  which  a  rub  is  usually  never  heard  at  all.  Most  commonly  peri- 
cardial friction  is  a  to-and-fro  rubbing  sound  which  to  the  trained  ear 
is  evidently  quite  superficial;  pressure  will  modify  it,  but  the  tender- 
ness over  the  cardiac  region  should  make  the  attempt  a  cautious  one. 

Often  at  first  quite  soft  in  character,  later  it  may  be  loud  and  harsh 
and  obscure  all  other  auscultatory  signs.  Sometimes  it  is  only  heard 
during  systole  and  then,  if  it  is  faint,  it  may  be  mistaken  for  an  endo- 
cardial bruit.  There  are  writers  who  hold  that  the  to-and-fro  friction 
rub  cannot  be  mistaken  for  an  endocardial  sound,  but  the  difficulty  may 
be  a  very  real  one  when  a  double  aortic  murmur  is  present  as  well 
as  pericarditis.  Generally  the  first  spot  at  which  the  rub  is  heard  is 
over  the  large  vessels  at  the  base  of  the  heart,  and  another  favorite 
area  is  at  the  horizontal  nipple-level  immediately  to  the  left  of  the 
sternum.  This  area  in  either  case  may  increase  with  great  rapidity, 
and  within  tw^enty-four  hours  the  friction  may  become  general. 

Because  of  its  extreme  value,  I  place  this  physical  sign  before  all  the 
other  evidences  of  pericarditis,  but  it  is  necessary  also  to  make  a  careful 
and  complete  examination  of  the  heart  on  the  classical  lines  of  inspec- 
tion, palpation,  percussion,  and  auscultation.  It  will  be  found  that, 
in  the  severe  and  acute  cases,  the  action  of  the  heart  is  greatly  excited 
and  the  impulse  diffuse.  The  area  of  deep  cardiac  dulness  is  increased 
and  may,  as  the  illness  advances,  become  literally  enormous.  It  is  an 
increase  upward  as  well  as  laterally,  and  with  it  there  is  also  an  increase 
in  the  area  of  superficial  cardiac  dulness. 

The  stethoscope,  in  addition  to  demonstrating  the  pericardial  friction, 
conveys  better  than  any  other  means  the  reality  of  the  cardiac  excite- 
ment, and  by  it  in  most  cases  a  mitral  systolic  bruit  can  be  detected 
at  a  deeper  level  than  the  friction  rub,  for  with  pericarditis  there  is  as 
a  rule  endocarditis. 

The  excited  action  of  the  heart,  the  rapid  sounds,  the  bruit  and 
friction  rub,  together,  give  a  curious  tumultuous  noise  which  baffles 
description,  but  which,  when  once  heard,  is  very  characteristic  of 
rheumatic  pericarditis. 

All  are  agreed  that  there  is  an  increase  in  the  quantity  of  fluid  in 
the  pericardial  sac  coincident  with  the  early  inflammation,  and  all  are 
agreed  that  there  is  comparatively  often  in  the  later  stages  of  peri- 
carditis a  very  great  increase  in  the  area  of  precordial  dulness.  The 
usual  explanation  formerly  given  for  this  great  increase  in  the  cardiac 
dulness  was  that  there  was  much  exudation,  but  now  we  know  it  is 
mainly  the  dilatation  of  the  heart  and  not  the  fluid  which  explains  this 
occurrence. 

At  first,  then,  some  muffling  of  the  cardiac  sounds  may  be  detected, 
and  the  early  friction  may  become  faint  or  even  disappear,  and  these 


70S 


DISEASES  OF   THE  HEART  AM)   BLOODVESSELS 


mean  that  some  considerable  exudation  has  taken  phice.  Yet  I  beheve 
myself  correct  in  statiiif;  that  far  more  frcfjuently  this  phase  is  not  to 
be  detected  at  all,  and  yet  the  area  of  pericardial  dulncss  increjises  l)oth 
to  the  ri<;ht  and  to  the  left  and  nj)\vard.  A  lar^c  cffnsion  in  the  rheumatic 
pericarditis  of  childhood  must  be  extremely  rare.  I  have  never  seen 
one,  after  death,  so  large  that  it  needed  paracentesis  during  life,  but  I 
have  seen  many  which  during  life  were  thought  to  need  it,  and  in  a 
few  of  these  the  thought  deterniined  action,  a  needle  was  introduced, 
and  blood  drawn  from  the  heart.  There  is  then  a  different  explanation 
needed  for  the  phenomenon  of  the  enlargement  of  the  precordial  dulness, 
and,  a.s  has  been  already  insisted,  that  explanation  is  acute  dilatation  of 
the  heart  itself. 


Fig. 152 


Rbeumatic  pericarditis.    Thie  pericardium  has  been  opened  and  shows  the  plastic  exudation. 


Acute  general  pericarditis  is  clearly  a  very  dangerous  condition,  not 
so  much  because  of  the  immediate  risk  to  life,  but  because  it  implies  in 
most  cases  a  carditis,  which  leaves  the  heart  permanently  weakened.  It 
is  difficult  to  give  precise  dates  for  the  duration  of  the  acute  stage,  causes 
differ  so  in  this  respect.  One  child  may  have  definite  pericarditis  and 
yet  all  the  physical  signs  clear  up  in  a  week;  another  may  drift  into  a 
subacute  condition  which  lasts  for  many  weeks,  while  in  others  again 
three  weeks  may  be  sufficient— not  for  the  heart  to  recover— but  for 
the  signs  of  pericarditis  to  entirely  subside. 

It  is  so  also  with  the  symptoms:  some  children,  except  for  breathless- 
ness,  some  pain  and  fever,  suffer  but  little,  and  take  their  food  throughout 


RHEUMATIC   HEART  DISEASE 


709 


the  attack  with  enjoyment.  But  the  virulent  cases  show  very  plainly 
the  fatal  injury  to  the  heart.  Thus,  livid  pallor  and  rapidly  progressing 
anemia,  breathlessness  amounting  to  orthopnea,  and  pain,  are  significant 
symptoms.  Even  more  dangerous  ones  are  continual  restlessness, 
sleeplessness,  and  vomiting.  It  is  in  such  cases  as  these  that  the  pre- 
cordial area  becomes  enormously  increased,  the  pulse  rises  to  130  to 
150,  and  is  small,  irregular,  and  of  low  tension.  Yet  there  is  no  striking 
edema,  but  toward  the  end  of  life  there  is  some  puffiness  of  the  ankles 
or  lower  extremities.     With  the  failure  of  the  heart,  the  liver  enlarges 


Fig. 153 


^^^^^Hp^^ 

W^L    q^k                  J^^H 

^            <j| 

Ai^H 

■         1 

K..^..^.a 

Malignant  endocarditis.    The  heart  of  a  child  ;  the  aortic  valve  is  exjxjsed  and  shows  a  large 
vegetation,  the  result  of  malignant  endocarditis. 


and  may  extend  below  the  umbilicus  and  be  tender  to  the  touch.  The 
lungs  become  congested  at  their  bases,  and  fluid  may  be  found  in  both 
pleurae.  Very  often  also  there  are  true  rheumatic  pleurisy  and  pleuro- 
pericarditis,  and  in  rare  cases  an  acute  edema  of  the  lungs  develops 
with  great  rapidity  and  causes  a  rapid  death.  The  urine  in  these  later 
stages  is  scanty  and  albuminous. 

When  death  occurs  in  a  first  attack  of  carditis — a  rare  event — these 
are  the  symptoms  to  be  expected,  and  the  actual  cause  of  death  is 
generally  sudden  cardiac  failure.  The  temperature  for  days  may  be 
subnormal.    Fortunately  the  more  usual  course  of  pericarditis  is  toward 


■10 


DISEASES  OF   THE  HEART  AXD  BLOODVESSELS 


recovery,  and  then  the  general  concUtion  improves,  the  face  looks  less 
pinched  and  is  a  better  color,  the  pulse  and  respiration  rate  diminish, 
the  area  of  cardiac  dulness  lessens,  and  the  temperature  quietly 
approaches  the  normal.  The  liver  becomes  smaller  antl  the  urine 
free  from  albumin,  if  any  has  been  present.  The  recovery,  it  is  true, 
may  be  slow  and  interrupted  by  relapses,  but  it  is  far  more  common 
than  the  fatal  result.  Yet  it  must  be  admitted  that  this  recovery  is  not, 
as  a  rule,  a  perfect  one,  for  the  opposing  endothelial  surfaces  of  the 
pericardium  have  been  damaged,  and  adhesion,  more  or  less  complete, 
is  to  be  expected. 

Fig.  154 


'^^'tA 


^^m 


.  V 


Endocarditis,  chorea,  and  rheumatic  fever.    Numerous  diplocoeci  are  present  in  the  valve  tissues. 
The  vegetations  are  small  as  in  simple  rheumatic  endocarditis,  but  there  are  numerous  diplocoeci. 

Lastly,  it  should  be  clearly  recognized  that  at  the  bedside  rheumatic 
pericarditis  must  often  be  looked  upon  as  only  one  manifestation  of 
the  rheumatic  infection,  and  that  the  true  history  of  the  illness  is  one 
in  which  this  pericarditis  is  only  an  inciflent.  The  temperature  chart 
(Fig.  151)  shown  on  page  703  is  a  good  illustration  of  this  truth.  (See 
Figs.  149,  152  and  154.) 

Myocardial  Damage. — This  can  be  divided  roughly  into  two  groups: 
the  first  a  small  one  in  which  are  placed  the  rare,  acute,  and  fatal  cases 
of  rheumatic  myocardial  disease,  which  will  be  treated  of  later;  the 
second  a  larger  one,  difficult  to  recognize  with  confidence,  but  probal)ly 
more  common  than  is  usually  supposed.  In  these  the  damage  is  less 
severe,  but  the  cardiac  valves  and  pericardium  escape,  or,  at  the  most, 
the  mitral  valve  is  slightly  damaged. 


RHEUMATIC  HEART  DISEASE  711 

Cases  in  this  second  group  begin,  just  as  other  rheumatic  cases  of 
moderate  severity,  with  some  dilatation  of  the  heart  and  perhaps  other 
signs  of  rheumatism,  but  the  heart  remains  large  and  the  pulse  rapid 
and  irregular;  the  child  is  breathless,  anemic  and  excitable,  and  very 
easily  tired.  There  may  be  a  systolic  murmur  which  disappears  with 
recovery.  It  is  difficult  to  be  sure  there  is  not  some  endocarditis,  but  if 
there  is  it  cannot  be  responsible  for  the  cardiac  weakness,  which  is 
quite  out  of  proportion  to  the  amount  of  endocarditis  present,  and  some- 
times very  persistent.  But  before  the  conclusion  is  arrived  at,  that  the 
cardiac  wall  is  at  fault,  it  is  important  to  assure  one's  self  that  there  has 
not  been  a  previous  pericarditis,  or  that  the  mitral  valve  is  not  narrowed 
by  some  insidious  and  intractable  endocarditis. 


CHAPTER   XXIX. 

CHRONIC   RHEUMATIC  HEART  DISEASE— TREATMENT  OF 
RHEUMATIC  HPURT  DISEASE. 

CHRONIC  RHEUMATIC  HEART  DISEASE. 

A.    The  Stage  of  Compensation. 

Symptomatology. — When  the  acute  rheumatic  illness  is  over,  the 
daniaii;*'  which  is  (generally  left  behind  is  slowly  corrected  by  the 
development  of  hypertrophy  of  the  heart.  In  this  way  health  and 
strength  are  restored,  and  if  not  to  the  former  degree  of  perfection, 
yet  often  so  far  a.s  to  enable  the  child  to  live  a  happy  and  useful  life. 
The  lesions  are  now  said  to  be  compensated,  and  it  is  all  important  to 
recognize  the  factors  in  this  compensation. 

Mitral  Regurgitation. — During  the  systole  of  the  left  ventricle  some 
blood  is  forced  back  through  the  incompetent  mitral  valve  into  the  left 
auricle.  The  left  auricle  must  then  be  dilated,  for  it  will  contain  at  the 
end  of  its  diastole  the  usual  supply  of  blood  from  the  pulmonary  veins, 
together  with  the  amount  regurgitated.  The  left  ventricle,  also,  will  be 
dilated  to  receive  a  larger  supply  on  the  systole  of  the  auricle.  Both 
chambers  will  hypertrophy  in  order  to  properly  discharge  the  increased 
quantity  of  blood.  The  nuisculature  of  the  left  auricle  is,  however,  but 
comparativelv  feeble,  and  thus  it  follows  that,  when  the  regurgitation 
is  considerable,  difficulty  will  be  felt  in  the  pulmonary  circulation.  In 
order  to  overcome  this,  the  right  ventricle  is  called  upon  for  increased 
effort  and  so  hypertrophies.  When  this  hypertrophy  l)egins  to  fail,  the 
tricuspid  ring  dilates  with  the  general  dilatation  of  the  ventricle,  and 
relative  incompetence  of  this  valve  will  result.  This  incompetence,  in 
turn,  Ls  to  some  extent  compensated  for  by  dilatation  and  hypertrophy 
of  the  right  auricle.  The  power  of  this  auricle  is  but  slight,  and  so, 
last  of  all,  the  systemic  veins  feel  the  strain  of  the  back  pressure,  and 
the  cardinal  signs  of  tricuspid  regurgitation  are  manifested. 

Mitral  Stenosis. — In  pure  mitral  stenosis,  the  difficulty  is  a  more 
serious  one,  for  immediately  in  front  of  the  comparatively  weak  left 
auricle  there  lies  the  narrow  opening  of  the  mitral  valve.  Hypertrophy 
of  the  auricle  is  needed,  and  soon  the  strain  is  felt  also  in  the  pulmonary 
circuit.  The  right  ventricle  must  come  to  the  rescue,  and  hypertrophy. 
When  the  right  ventricle  fails,  the  sequence  of  events  is  as  in  mitral 
regurgitation.  A  strong  right  ventricle  is  the  safeguard  of  the  patient. 
The  left  ventricle  in  severe  cases  receives  less  blood  than  normal  and 
the  muscle  may  atrophy.  The  small  output  of  this  ventricle  is  shown 
by  the  stunting  of  the  child  in  development. 
(712) 


CHRONIC   RHEUMATIC  HEART  DISEASE  713 

Aortic  Regurgitation. — The  result  of  this  lesion  is  that  during  diastole 
a  certain  quantity  of  blood  passes  back  through  the  damaged  valve  into 
the  left  ventricle,  which  contains  in  addition  the  usual  supply  from  the 
left  auricle.  The  left  ventricle  is  dilated  to  receive  the  increased  quantity, 
and,  to  carry  out  its  increased  work,  it  hypertrophies.  When  aortic 
regurgitation  is  very  considerable  and  the  dilatation  of  the  left  ventricle 
is  great  from  failure  to  cope  with  the  strain,  the  mitral  valve  may  become 
relatively  incompetent  and  mitral  regurgitation  will  then  supervene  upon 
aortic  regurgitation.  The  enormous  enlargement  of  the  left  ventricle 
that  can  residt  in  the  adult  from  aortic  regurgitation  is  not  often  seen 
in  the  child,  for  aortic  lesions  are  rarely  severe  in  the  young. 

Aortic  Stenosis. — The  strain  is  first  felt  during  the  systole  of  the  left 
ventricle,  and  in  order  to  force  the  blood  through  the  narrowed  orifice 
there  must  be  hypertrophy  of  the  left  ventricle.  Later,  when  the  ventricle 
fails,  there  will  be  dilatation  and  perhaps  mitral  incompetence,  followed 
by  the  secondary  results  of  mitral  regurgitation. 

Tricuspid  regurgitation  and  stenosis  can  be  understood  from  what 
has  already  been  written  upon  the  similar  conditions  at  the  mitral 
orifice. 

Combined  Lesions. — A  very  common  result  of  rheumatic  fever  is  a 
combination  of  mitral  stenosis  and  regurgitation;  the  strain  then  is  upon 
the  left  auricle,  pulmonary  circuit,  and  right  ventricle. 

Another  result  is  mitral  and  aortic  regurgitation,  in  which  case  much 
hypertrophy  of  the  left  ventricle  is  needed. 

When  there  is  a  generally  adherent  pericardium,  there  is,  as  a  rule, 
some  general  dilatation  and  hypertrophy  of  the  heart,  but  it  is  difficult 
to  recognize  to  what  extent  this  enlargement  of  the  heart  is  the  result 
of  the  adhesion,  of  the  usually  coincident  valvular  disease,  or  of  the 
myocardial  weakness. 

There  are  exceptional  cases  in  which  the  heart,  without  the  occurrence 
of  endocarditis,  is  strangled  and  atrophied  by  extreme  pericardial 
adhesion  and  thickening. 

Diagnostic  Points. — The  clinical  features  of  these  cardinal  lesions  are 
as  follows: 

Compensated  Mitral  Regurgitation. — There  is  often  nothing  char- 
acteristic in  the  aspect  of  the  child,  though  there  may  be  some  breathless- 
ness  on  exertion  and  cough,  a  tendency  to  bronchitis,  and  a  slightly 
purple  tinge  to  the  lips  and  face. 

The  pulse  is  more  rapid  than  usual,  easily  compressible,  of  fair 
volume,  and  either  regular  or  very  slightly  unequal  in  the  strength  of 
the  individual  waves. 

The  cardiac  impulse  is  forcible,  and  situated  external  to  the  left 
nipple  line  in  the  fifth  space  or  touching  the  fifth  rib,  and  the  cardiac 
area  is  increased  to  some  extent  both  to  the  right  and  left.  At  the 
impulse  there  is  a  systolic  murmur  traceable  toward  the  axilla  and 
often  audible  at  the  back  on  the  left  side  in  the  infrascapular  region. 
The  second  sound  at  the  pulmonary  area  is  accentuated  and  reduplicated. 

If,  as  is  so  often  the  case,  there  is  some  slight  mitral  constriction  as 


714  DISEASES  OF   THE   HEART   AXD    BLOODVESSELS 

well,  tlu'ir  will  be  heurd,  in  addition,  ut  the  impulse  either  a  slight 
runihle  immediately  before  the  first  sound,  or  the  same  in  mid-diastole, 
or  immediately  following  the  second  sound.  This  rumbling  sound  is, 
as  a  rule,  strictly  localized  to  the  impulse  and  not  conducted.  On 
palpation  the  hand  may  feel  a  presystolic  thrill. 

Auriic  Ra/un/itation.—U  this  is  well  marked,  there  are  usually  pallor, 
nervousness,  and  some  dyspnea  upon  exertion;  but  none  of  these  symp- 
toms may  be  present.  The  pulse  is  incrcjised  in  rate,  it  is  usually 
regular,  and  the  wave  large,  sudden,  and  ill-sustained.  The  radial 
artery  may  pulsate  visibly,  and  the  pulse  may  be  audible  on  putting 
the  wrist  to  the  ear.  There  is  capillary  pulsation  on  pressing  the  "(pnck" 
of  the  nails,  or  stroking  the  forehead  smartly.  The  impulse  is  forcible, 
and  the  area  increased  to  the  left  and  downward.  The  cardinal  sign 
is  a  diiustolic  murmur,  sometimes  long  and  blowing,  at  other  times  short 
and  soft.  The  position  of  maximiun  intensity  is  very  variable;  it  is 
often  heard  most  distinctly  in  the  third  left  space  close  to  the  sternum, 
sometimes  at  the  inner  end  of  the  second  right  space,  or  behind  the 
sternum  at  that  level,  or  over  the  ensiform  cartilage.  It  can,  in  some 
cases,  be  traced  down  the  right  margin  of  the  sternum,  or  even  be  heard 
at  the  impulse.  This  murmur,  in  my  experience,  is  more  localized  in 
the  child  than  in  the  adult. 

Aortic  Stenosis. — This  is  a  very  rare  condition  in  children.  There  is 
brcathlessness  on  exertion,  and  the  growth  of  the  child  is  stunted. 
The  pulse  is  rapid,  the  wave  small  and  not  easily  compressible.  The 
impulse  is  forcible  and  displaced  downward  and  outward.  The  area 
is  increased,  as  in  aortic  regurgitation.  The  cardinal  sign  is  a  harsh 
.systolic  murmur  which  gives  a  systolic  thrill  to  the  hand.  It  is  heard 
most  distinctly  over  the  aortic  cartilage,  and  is  traceable  into  the  large 
vessels  of  the  neck. 

Tricuspid  Regurgitation. — ^This  is  so  intimately  connected  with  the 
details  of  failing  compensation  that  it  will  be  dealt  with  under  that 
heading. 

Adherent  Pericardium. — I  think  it  is  impossible  to  diagnose  this  in 
a  child  with  any  certainty,  except  in  rare  cases.  When,  however, 
there  is  indurative  mediastino-pericarditis,  which  w^ill  be  described 
later,  there  may  be  sufficient  evidence.  I  have  seen  experienced  observ- 
ers time  after  time  make  the  diagnosis  of  adherent  pericardium  upon 
the  evidence  that  is  usually  accepted  as  sufficient,  and  yet  be  wrong. 
Adhesion  is  a  very  common  result  of  pericarditis,  and  it  is  a  common 
event  in  the  autopsy-room;  its  occurrence  during  life  can  thus  be 
often  guessed  correctly  from  the  history  of  the  illness,  but  it  is  no 
more  than  a  likely  guess. 

When  there  is  fixation  of  the  heart  to  the  chest  wall  and  pleura,  then 
the  following  are  the  more  important  physical  signs  of  adhesion: 

Immobility  of  the  apex  beat,  upon  deep  respiration  and  upon  change 
of  posture.  This  sign  is  of  little  value  in  children,  for  a  large  heart, 
even  without  pericardial  adhesion,  will  not  move  with  a  change  of 
posture  in  a  small  chest. 


CHRONIC  RHEUMATIC  HEART  DISEASE  715 

There  is  systolic  recession  of  the  intercostal  spaces  and  cartilages  to 
the  left  of  the  sternum.  In  some  cases  the  epigastrium  and  lower  end 
of  the  sternum  are  drawn  in  with  systole,  and,  as  Dr.  John  Broadbent 
has  pointed  out,  the  sides  and  posterior  walls  of  the  lower  part  of  the 
thorax  may  also  show  this  same  retraction. 

A  diastolic  shock  may  be  felt  by  the  hand,  placed  over  the  area  of 
retraction  to  the  left  of  the  sternum,  and  is  due  to  the  elastic  recoil  of 
the  chest  wall  at  the  commencement  of  diastole.  There  will  also  be 
cardiac  enlargement,  due  to  hypertrophy  and  dilatation,  and  the  respir- 
atory movements  of  the  diaphragm  may  be  embarrassed  by  firm  peri- 
cardial adhesions. 

Diastolic  collapse  of  the  veins,  in  conjunction  with  systolic  recession 
of  the  intercostal  spaces,  as  described  by  Friedreich,  does  not  seem 
♦to  have  met  with  general  acceptance. 

Lastly,  the  physician  may  find  that  the  damage  to  the  heart  is  greater 
than  would  be  expected  from  some  simple  valvular  lesion,  and  in  this 
way  be  led  to  suspect  pericardial  adhesion. 

Multiple  Valvular  Lesions. — It  is  not  uncommon  for  two  valves  to  be 
damaged  simultaneously  in  an  attack  of  rheumatism,  and  so  far  as 
children  are  concerned,  where  aortic  and  mitral  incompetence  are  found, 
it  is  more  probable  that  both  arise  from  the  rheumatic  infection  than 
that  the  mitral  regurgitation  is  a  secondary  result  of  the  aortic  regurgi- 
tation. In  other  words,  the  mitral  regurgitation  in  these  cases  is  due 
to  endocarditis  and  not  to  relative  incompetence. 

The  aortic  and  mitral  lesion  is  the  most  usual  combination  and  it  is 
a  serious  condition.  In  four  consecutive  cases,  coming  under  my  notice, 
three  died  within  eighteen  months  from  rheumatic  complications,  and 
the  fourth  is  anemic,  highlv  nervous,  and  short  of  breath.^ 

The  evidence  of  the  double  lesion  is  usually  definite,  but  unless  the 
practitioner  is  careful  he  may  overlook  the  aortic  disease,  the  diastolic 
murmur  of  which  is  often  most  clearly  heard  to  the  left  of  the  sternum. 

Mitral  Stenosis. — It  might  seem  that  this,  of  all  the  lesions,  was  the 
most  stationary,  yet  it  is  not  so,  and  close  inquiry  will  prove  that  it 
is  often  steadily  progressive.  Advanced  mitral  stenosis  is  rare  under 
twelve  years  of  age,  and  yet  mitral  endocarditis  is  very  common,  and 
may  be  met  with  as  early  as  four  years  or  younger;  certainly  after  six 
years  it  is  comm.on  enough,  and  often  severe.  If,  then,  mitral  stenosis 
was  the  usual  result  of  the  healing  of  an  inflamed  valve,  it  should  be 
common  enough,  for  between  six  and  twelve  years  of  age  there  is  ample 
time  for  the  processes  of  scarring  and  cicatricial  contraction. 

Then,  again,  the  cases  of  mitral  stenosis  which  are  met  with  have 
usually  one  remarkable  feature  in  their  illness,  and  that  is  the  absence 
of  any  very  definite  history  of  an  acute  attack  of  rheumatism,  although 
close  inquiry  will  often  elicit  a  prolonged  history  of  indefinite  rheu- 
matism. There  can  be  little  doubt,  I  think,  that  this  form  is  the  result 
of   a   persistent,   smouldering,   rheumatic   inflammation   of   the   entire 

1  Since  writing  this  article  I  liave    published  in  the  British  Medical  Journal,  October  7,  1905, 
details  of  twenty-one  such  eases. 


716  DISKASl-S  OF   THE   HEART  ASD   BLOODVESSELS 

thickness  of  the  mitnil  valve,  mitral  ring,  and  ciionh^  tendinere,  which  I 
would  compare  to  chronic  periarticular  rheumatism.  That  the  inflam- 
mation wjis  a  peculiar  one  was  the  opinion  of  Dr.  Sansom  some  twenty 
years  ago.  To  illustrate  my  meaniii<>-  by  analogy,  it  is  comparable  to 
the  fibroid  type  of  tuberculosis  of  the  lungs. 

Although  there  may  be  no  definite  history  of  rheumatism  at  all,  in  a 
certain  numb-r  of  ciuses  chorea,  of  a  persistent  and  intractable  type,  is 
a  witness  to  the  activity  of  the  rheumatic  process. 

IVIitral  stenosis  is  well  known  to  be  more  connnon  in  females,  and  I 
believe  this  to  be  because  all  rheumatic  affections  are  more  liable  to  be 
chronic  and  smouldering  in  the  female. 

The  connnenccment  of  mitral  stenosis  is  most  insidious  and  often 
enough  the  child  is  never  brought  to  the  doctor  until  the  disease  is  well 
advanced,  for  there  may  be  no  pain  nor  discomfort.  When  its  develop-* 
ment  can  be  traced  these  are  the  most  usual  phenomena: 

The  pulse  is  increasetl  in  rate,  at  first  regular,  small  and  not  very 
ea.sily  compressible.     Sometimes  it  feels  like  a  thin  wire. 

If  there  is  a  regurgitant  bruit  this  slowly  disappears  and  leaves  a  first 
sound  which  is  short  and  ends  abruptly.  Then  the  curious  reduplication 
of  the  second  sound  (tut-tut) ,  which  points  to  some  thickening  of  the 
valve  becomes  more  pronounced  and  longer,  and  may  occupy  most  of 
the  diastole.  With  this  development,  a  presystolic  thrill  can  be  felt  in 
the  region  of  the  impulse,  and  the  pulmonary  second  sound  is  accent- 
uated. Finally,  the  so-called  reduplication  at  the  impulse  becomes  a 
well-marked  presystolic  murmur,  leading  up  to  a  short,  sharp,  first 
sound. 

The  clinical  picture  of  severe  mitral  stenosis  is  an  interesting  one. 

The  small  output  of  blood  from  the  left  ventricle  in  severe  mitral 
stenosis  leads  to  stunting  of  the  growth  of  the  child.  There  is  often  a 
persistent,  red  flush  on  the  cheeks,  and  the  eyes  have  a  very  curious 
translucent  brightness. 

The  disposition  is  singularly  patient  and  attractive,  a  result  partly 
of  the  refining  influence  of  invalidism  and  partly  of  the  altered  cerebral 
circulation  due  to  the  valvular  defect. 

The  circulation  in  the  extremities  is  poor  and  the  fingers  often  blue 
and  cold.  This  imperfection  in  the  circulation  may  reach  such  a  degree 
that,  when  the  heart  fails,  gangrene  of  the  extremities  may  result. 

B.   Ruptured  Compensation. 

The  compensation  of  a  damaged  heart  is  upset  by  many  influences, 
but  more  especially  by  a  relapse  of  rheumatism.  Overexertion,  rapid 
growth  with  anemia,  pulmonary  affections,  nervous  strain,  and  infec- 
tious diseases  are  all  of  them  occasional  factors.  Again,  when  compen- 
sation has  been  effected  only  with  great  difficvdty,  and  its  margin  of 
reserve  is  consequently  very  narrow,  even  the  ordinary  exertion  of 
every-day  life  may  be  too  much  for  the  crippled  heart. 

The  breakdown  in  the  health  of  the  child  is  thus,  as  a  rule,  a  complex 


CHRONIC  RHEUMATIC   HEART  DISEASE  717 

process,  in  which  active  rheumatism,  and  faikire  of  the  heart  to  perform 
its  function  on  account  of  valvular  defects,  take  varying  prominence. 
In  some  cases  it  is  the  active  rheumatism  that  is  the  prominent  factor; 
in  others  it  is  the  failure  of  compensation. 

The  group  in  which  active  rheumatism  is  prominent  will  need  no 
further  description,  for  to  understand  them  we  have  only  to  apply  the 
principles,  which  have  been  already  given  under  acute  rheumatic  heart 
disease,  to  a  heart  already  maimed  by  previous  attacks. 

The  second  group  includes  those  cases  in  which  the  rheumatism  has 
merely  stepped  in  and  pushed  the  heart,  as  it  were,  over  the  brink  of 
the  precipice,  upon  which  it  was  already  standing.  These  will  need 
further  description. 

Dilatation  and  Hypertrophy  of  the  Heart. — It  will  possibly  make  the 
subject  clearer  if  a  few  lines  are  devoted  to  dilatation  and  hypertrophy 
apart  from  the  valvular  defects. 

Dilatation  may  either  be  a  necessary  result  of  valvular  incompetence — 
a  provision  for  the  accommodation  of  blood  which  has  leaked  through 
the  opening — or  a  result  of  the  failure  of  the  myocardium  to  cope  with 
its  difficulties. 

Dilatation. — Where  there  is  dilatation  it  shows  itself  by  a  quickened 
low-tension  pulse  which  is  sometimes  irregular.  The  impulse  of  the 
heart  is  diffuse  and  tapping  or  may  not  be  palpable.  The  area  of 
cardiac  dulness  is  increased  to  the  left,  and,  if  the  dilatation  is  general, 
to  the  right  as  well.  The  first  sound  at  the  apex  is  short  and  clear,  and 
is'  sometimes  followed  by  a  soft  systolic  murmur.  When  the  dilatation 
is  very  great,  the  systolic  interval  between  the  sounds  is  shortened. 
The  pulmonary  second  sound  is  usually  accentuated.  The  symptoms 
are  breathlessness,  pallor,  insomnia,  and  night  terrors,  cough  and  some- 
times slight  edema. 

Hypertrophy  is  salutary,  but  the  very  fact  of  its  occurrence  is  an 
evidence  that  the  damage  which  the  heart  has  sustained  is  a  very  real 
one.  In  the  complicated  lesions  of  rheumatic  heart  disease  it  is  very 
necessary'  to  search  for  and  recognize  the  existence  both  of  dilatation 
and  of  hypertrophy,  which  in  simpler  lesions,  such  as  those  of  renal 
heart  disease,  are  so  prominent  that  they  can  hardly  be  overlooked. 

Hypertrophy  is  measured  by  the  well-sustained  character  of  the  pulse, 
the  forcible  and  localized  impulse,  and  the  enlargement  of  the  cardiac 
area  downward  and  to  the  left.  The  first  sound  is  muffied  and  slightly 
prolonged,  if  the  hypertrophy  is  great. 

Symptoms. — The  early  symptoms  of  ruptured  compensation  are 
dyspnea  on  exertion,  cough,  precordial  pain,  palpitation,  wasting, 
epistaxis,  loss  of  appetite,  and  insomnia.  Edema  is  not  a  prominent 
symptom,  and  is  often  absent.  The  cases  in  which  great  edema  occurs 
are,  as  a  rule,  those  in  which  there  is  an  unusual  amount  of  valvular 
damage,  but  a  strong  myocardium.  In  mitral  stenosis,  as  Sir  William 
Broadbent  has  emphasized,  ascites  may  occur  without  edema. 

Aortic  Disease. — Turning  to  the  heart  itself,  there  are  two  chief 
forms   of  valvular  disease  to  be  considered,  namely,  the  aortic  and 


71S  DISEASES  OF   THE   HEART   AM)    BLOODVESSELS 

miiral.  Suc-h  cases  of  aortic  disease  as  I  have  seen  in  cliililluKxl  have, 
when  coin|)ensation  has  failed,  eillier  died  from  acute  rheumatic  carditis, 
or  liave  lost,  for  the  time  hein^',  tiieir  aortic  characteristics  and  become, 
to  all  intents  and  purposes,  mitral  in  type.  I  have  never  met  with  that 
sudden  syncope  which  is  comparatively  frequent  in  the  aortic  disease 
of  adult  life. 

Mitral  Disease— \\'\\v\\  the  heart  with  mitral  lesions  fails,  it  is 
because  the  right  ventricle  gives  way  antl  tricuspid  regurgitation  super- 
venes. 

It  will  be,  then,  a  sufficiently  accurate  impression  if  this  phase  of 
ru()tur(>(l  compensation  be  looked  upon  as  essentially  a  condition  of 
tricuspid  regurgitation,  the  features  of  which  it  is  most  essential  to 
recognize.     They  are: 

1.  Dyspnea  and  cyanosis.  2.  An  enlargement  of  the  heart,  especially 
to  the  right  of  the  sternum,  due  to  dilatation  of  the  right  auricle.  3. 
The  development  of  a  soft  systolic  murmur  in  the  tricuspid  area.  4.  An 
enlarged  and  tender  liver.  5.  Full  and  sometimes  pulsating  veins  in 
the  neck.  6.  Congestion  of  the  bases  of  the  lungs.  7.  Edenui,  which 
is  but  rarely  extensive.     8.  A  scanty  and  albuminous  urine. 

When  stenosis  of  the  mitral  valve  is  extreme  the  pulmonary  engorge- 
ment is  intense,  and  there  may  be  pulmonary  hemorrhage  with  or 
without  infarction.  Further,  there  may  be  paroxysmal  attacks  of  palpi- 
tation and  pain.    Even  sudden  death  may  occur  in  mitral  stenosis. 

For  successful  treatment,  a  clear  mental  picture  must  also  be  obtained 
of  the  results  of  the  tricuspid  regurgitation.  The  backworking  eml)ar- 
rasses  the  fimctions  of  all  the  viscera.  The  liver  })ecomes  fatty  and 
nutmeg  in  appearance;  the  kidneys  are  congested  and  hard;  the  spleen 
is  shrunken  and  firm;  the  stomach  is  dilated,  the  walls  thickened,  and 
the  mucous  membrane  coated  with  thick  mucus. 

Congestion  of  the  bronchial  mucous  memV)rane  disposes  to  bronchitis, 
and  congestion  of  the  lungs  to  hypostatic  y)iieumonia.  Lastly,  the 
cerebral  circulation  is  disordered,  and  night  terrors,  dreams,  and  insomnia 
result. 

Physical  Signs.  Aortic  Lesions. — As  I  have  already  mentioned, 
when  compensation  fails,  the  aortic  lesion  is  masked.  The  collapsing 
character  of  the  pulse  and  the  large  wave  are  modified.  The  aortic 
diastolic  murmur  may  disappear  completely  and  leave  only  a  suspicious 
feebleness  or  absence  of  the  second  sound  in  the  aortic  area. 

This  masking  of  the  lesion  is  of  consiflerable  importance,  and  the 
cautious  physician  will  not  give  a  definite  opinion  upon  the  exact  con- 
dition of  the  heart  when  he  has  seen  the  patient  but  once,  and  then  in 
this  stage  of  failure.  For,  when  the  heart  rallies  the  aortic  murnuir 
will  reappear,  to  the  surprise  of  a  hasty  diagnostician,  and  an  unsus- 
pected aortic  lesion  will  l)ecome  apparent. 

Mitral  Lesion.s. — The  heart  with  mitral  lesions  is  variously  affected 
by  ruptured  compensation. 

In  mitral  regurgitation  the  pulse  becomes  rapid  and,  sometimes, 
exceedingly  irregular.     The  systolic  mitral  bruit  is  more  prolonged, 


CHRONIC  RHEUMATIC  HEART  DISEASE  719 

and  may  entirely  replace  the  first  sound.  The  previously,  forcible 
impulse  of  the  left  ventricle  becomes  diffuse  and  tapping,  and  the 
accentuation  of  the  pulmonary  second  sound  disappears. 

In  mitral  stenosis  the  pulse  becomes  irregular  and  more  easily  com- 
pressible. The  presystolic  murmur  and  thrill  are  less  evident,  and 
eventually  may  disappear,  owing  to  the  feebleness  of  the  left  auricle 
and  right  ventricle.  There  are  then  left  a  short,  sharp  first  sound  at 
the  impulse,  but  with  no  murmur,  and  a  very  faint  or  even  absent 
second  sound.  With  failure  of  compensation,  the  accentuation  of  the 
pulmonary  second  sound  disappears  also. 

Course  of  the  Ilhiess. — The  duration  of  this  stage  of  ruptured  compen- 
sation varies  greatly,  sometimes  all  the  unfavorable  symptoms  appear 
step  by  step,  or,  on  the  other  hand,  only  a  few  develop,  and  then  treat- 
ment arrests  the  progress,  and  compensation  is  once  more  established. 
With  children  as  with  adults,  these  improvements  may  only  be  illusory, 
and  in  such  cases,  after  a  short  stationary  period,  the  downhill  course 
recommences  in  spite  of  every  remedy. 

Diagnosis  in  Rheumatic  Heart  Disease. — The  diagnosis  of  the  various 
forms  of  rheumatic  heart  disease  rests  upon  an  accurate  study  of  the 
physical  signs  and  symptoms  which  have  been  described  and  it  only 
remains  here  to  write  a  few  words  upon  the  general  diagnosis  of  the 
condition. 

This  is  based  upon  a  study  of  rheumatic  fever.  There  can  be  no 
doubt  that  rheumatic  fever  is  the  most  common  cause  of  heart  disease 
in  early  life,  and  when  confronted  with  a  case,  the  history  of  which 
affords  no  guidance,  but  the  nature  of  which  appears  in  no  way  unusual, 
it  is  the  safest  hypothesis  to  look  upon  the  condition  as  due  to  rheu- 
matism. This  cause,  however,  should  not  be  assumed  without  careful 
investigation.  Inquiries  should  be  made  into  the  family  history,  and 
into  the  occurrence  of  repeated  tonsillitis,  growing  pains,  and  erythemata 
and  subcutaneous  nodules  must  be  sought  for.  Chorea  is  usually 
rheumatic  in  origin,  and  even  if  there  is  no  history  of  rheumatism  it 
may,  nevertheless,  be  the  first  cardinal  evidence  of  the  disease.  Clinical 
experience  has  clearly  shown  that  a  child  w^ho  has  suffered  from  chorea, 
with  dilatation  of  the  heart,  may  a  year  later  come  under  treatment 
with  an  endocarditis  or  pericarditis  which  is  certainly  rheumatic. 

I  am  also  of  opinion  that  many  of  the  mysterious  cases  of  mitral 
stenosis  which  have  no  history  of  rheumatism  are  rheumatic  in  nature. 

Malignant  endocarditis  is  always  a  difficult  problem.  There  is  now 
a  good  deal  of  evidence  to  show  that  rheumatic  fever  is,  in  many  cases, 
a  factor,  but  it  is  uncertain  whether  the  majority  of  those  in  which  there 
is  a  previous  history  of  rheumatism  are  due  to  rheumatic  infection 
alone,  or  to  this  coupled  with  some  secondary  infection. 

Thus  the  general  diagnosis  of  rheumatic  heart  disease  is  based  more 
upon  a  study  of  rheumatic  fever  than  upon  the  actual  condition  of  the 
heart  itself. 

Prognosis  in  Rheumatic  Heart  Disease. — There  are,  unfortunately,  some 
great  difficulties  in  making  a  prognosis  in  rheumatic  heart  disease.     It 


720  DISEASi:S  OF    THE   HEART  A.MJ   BLOODVESSELS 

is  not  a  <iuestion  of  calculating;  the  extent  of  mechanical  defect,  but 
a  complex  problem  in  which  the  liability  to  repeated  attacks  of  rheuma- 
tism is  most  important.  We  have  not  yet  sufficient  knowledge  of  the 
laws  that  govern  a  rheumatic  infection;  nevertheless,  some  facts  are 
known  which  may  be  useful  in  assisting  one  to  give  a  prognosis.  Thus 
double  inheritance  usually  implies  a  liability  in  the  child  to  severe 
rheumatic  heart  disease.  The  younger  the  child,  the  worse  the  outlook; 
the  poorer  the  circumstances,  the  less  the  hope  of  avoiding  the  predispos- 
ing causes.     These,  then,  must  be  taken  into  account. 

In  considering  acute  rheumatic  heart  disease,  carditis  is  the  most 
dangerous  to  life,  mitral  incompetence  the  least,  with  the  exception  of 
the  early  dilatation,  from  which  tiiere  may  be  complete  recovery. 

The  insidious  cases  of  persistent  rheumatic  fever,  in  which  many 
of  the  rheumatic  lesions  make  their  appearance  one  after  another,  are 
most  grave,  and  as  Dr.  Cheadle  has  emphasized,  when,  in  such  cases, 
nodules  appear,  the  outlook  is  very  gloomy. 

It  is  a  common  experience  in  England  to  see  these  cases  drift  slowly 
down  hill.  They  niay  rally  for  some  months,  for  a  year  perhaps,  or 
even  longer,  but  even  when  at  their  best  there  is  a  history  of  fleeting 
pains  in  the  muscles  and  limbs,  which  tells  the  tale  of  a  persistent 
enemy. 

Acute  pericarditis  is  rarely  fatal  when  it  is  a  first  attack,  and  acute, 
simple  endocarditis  never;  when,  however,  the  heart  is  already  damaged, 
pericarditis  is  a  very  serious  matter  indeed.  The  details  of  the  prognosis 
in  such  cases  are  dealt  with  under  the  section  on  Acute  Rheumatic 
Heart  Disease  (p.  69.')). 

The  prognosis  in  chronic  heart  disease  is  surrounded  with  pitfalls. 
There  is  no  doubt  that  slight  regurgitant  mitral  lesions  are  often  com- 
pletely compensated,  and  leave  the  heart  almost  as  sound  as  before, 
and  even  slight  aortic  lesions  may  disappear. 

Mitral  stenosis  is  more  grave,  because  it  is  exceedingly  difficult  to 
say  that  the  lesion  is  really  arrested,  and  not  slowly  progressive.  If 
there  is  no  reason  for  believing  that  it  is  advancing,  and  the  absence 
of  sym])toms  shows  that  it  is  well  compensated,  a  useful  life  far  beyond 
childiiood  is  to  be  expected.  Yet  there  are  dangers  in  young  adult  life, 
especially  connected  with  childbirth,  which  cannot  be  overlooked. 
^Mitral  stenosis  is  clearly  incurable. 

In  estimating  the  amount  of  damage  that  has  resulted  from  a  valvular 
lesion,  the  symptoms  must  be  first  taken  into  account,  and  then  the 
extent  of  the  lesion  be  gauged  as  accurately  as  possible  by  the  amount 
of  hypertrophy  and  dilatation  of  the  heart,  and  by  the  character  of  the 
sounds  of  the  heart.  It  must  not  be  forgotten  that  a  loud  murmur  does 
not,  by  any  means,  imply  a  severe  lesion,  but  that  its  duration,  and 
the  extent  to  which  it  encroaches  upon  the  cardiac  sounds  are  of 
more  importance.  Combined  aortic  and  mitral  lesions  are  of  bad 
prognosis. 

It  will  be  remembered  that  adhesions  of  the  pericardium  are  not 
easy  lesions  to  diagnose;  and  so  it  will  not  be  hastily  concluded  that, 


UNUSUAL   TYPES  OF  RHEUMATIC  HEART  DISEASE         721 

because  there  has  been  an  attack  of  pericarditis,  such  a  comphcation 
has  necessarily  supervened,  or  that,  in  the  event  even  of  there  being 
pericardial  adhesion,  that  the  condition  is  necessarily  a  very  grave  one. 
When,  in  addition  to  the  pericarditis,  there  has  been  pleuropericarditis 
and  mediastinitis  with  adhesion,  the  prognosis  is  very  serious,  for  the 
heart  of  the  growing  child  is  hampered  at  every  beat. 

Each  failure  in  compensation  leaves  the  heart  at  a  lower  level  of 
efficiency. 

Lastly,  the  physique  of  the  child  influences  prognosis.  The  fragile, 
fair-haired  children,  with  small  limbs  and  frame,  are  bad  subjects  and 
they  need  very  gentle  treatment;  strong  drugs  upset  them,  and  heroic 
measures  alarm  them.  It  is  my  firm  belief  that  the  prognosis  in  such 
cases  is  more  grave  if  the  rheumatic  heart  disease  is  treated  as  an  enemy 
to  be  overcome  by  fierce  blows,  and  the  natural  processes  of  recovery 
placed  in  the  background. 


UNUSUAL  TYPES  OF  RHEUMATIC  HEART  DISEASE. 

Malignant  Endocarditis. — Malignant  endocarditis  is  one  of  the 
most  important  forms  of  endocarditis.  The  condition  variously  termed 
malignant,  ulcerative,  or  septic  endocarditis  is  rare  in  childhood,  but 
becomes  more  common  in  early  adult  life.  Many  infections  may  cause 
this  endocarditis,  and  sometimes  more  than  one  micro-organism  has 
been  isolated  from  the  damaged  valve.  The  usually  accepted  view  of 
the  condition  when  occurring  in  rheumatism  is  that  it  is  the  result  of 
a  secondary  infection  of  the  damaged  valves.  In  1902  Dr.  Paine  and 
I  showed  that  the  rheumatic  infection  might,  without  any  added  infec- 
tion, produce  malignant  endocarditis  in  man  and  animals,  and  for  this 
reason  it  is  considered  here  among  the  unusual  forms  of  rheumatic 
infection.  The  relation  of  rheumatism  to  malignant  endocarditis  is, 
according  to  this  view,  quite  a  consistent  and  rational  one  and  can  be 
stated  thus:  All  micro-organisms  which  attack  the  cardiac  valves  may 
produce  this  type  of  endocarditis,  and  among  the  most  important  of 
these  is  the  micro-organism  of  rheumatism. 

Pathology. — The  essential  feature  is  the  presence  of  the  micro- 
organisms in  great  numbers  in  the  vegetations  on  the  valves.  These 
vegetations  are  often  large  and  extend  from  the  valve  or  valves  on  to 
the  surfaces  of  the  auricles  or  ventricles,  on  to  the  chordte  tendinese,  or 
on  to  the  commencement  of  the  aorta.  In  the  most  rapidly  fatal  cases  the 
vegetations  are  small,  yet  enormous  numbers  of  the  infective  agent  are 
found  in  them  (Fig.  154). 

When  the  relations  of  these  vegetations  to  the  current  of  the  blood 
stream  is  recognized,  it  is  at  once  apparent  that  the  infection  must  be 
carried  all  over  the  body,  sometimes  in  the  form  of  detached  fragments 
of  the  infected  valve,  at  other  times  as  the  micro-oganisms  themselves 
which  fringe  the  border.  Whatever  the  cause  of  the  malignant  endo- 
carditis may  be,  it  is  apparent  that  the  systemic  infection  must  be  very 
46 


722  DISLWSICS  OF    Till-:   UF.AUT  AXD   I'.I.OODVESSELS 

severe,  and  tliiit  the  nuiterial  particles  detaeheil  by  the  blood  .stream 
will  give  rise  to  those  important  secondary  lesions  termed  infarcts. 

In  rheumatic  cases  the  mitral  valve  is  most  usually  affected,  though 
the  aortic  and  tricuspid  are  sometimes  damaged. 

The  figure  (154  )  shows  a  good  example  of  tlie  change  produced  in  the 
valves  in  man.  As  a  rule,  the  valve  that  is  attacked  has  been 
injured  by  previous  endocarditis;  but  the  interpretation  sometimes 
given,  that  the  micro-organisms  prefer  a  damaged  valve,  a{)pears 
to  me  le.ss  likely  than  that  the  resistance  of  the  patient  has  been  lowered 
by  previous  infections.  Then  the  vital  tissues  of  the  valve  are  less  able 
to  cope  with  the  fresh  attack,  or  it  may  be  they  harbor  the  bacteria 
in  a  resting  stage. 

It  Ls  essentially  a  local  j)rocess — therein  the  valve  is  the  Ijreeding 
focus  of  the  disease — and  if  this  could  be  cut  out  one  feels  the  illness 
might  be  arrested.  In  childhood  we  know  that  the  tendency  of  severe 
infections  is  to  generalize,  not  to  localize,  and  in  this  fact  probably  lies 
in  part  the  explanation  of  the  comparative  rarity  of  malignant  endo- 
cartlitis  in  the  young. 

In  a  .series  of  15  cases,  8  were  certainly  rheumatic  children;  2  were 
associated  with  empyema;  1  with  pyemia  from  suppurative  arthritis; 
1  with  tuberculosis  of  the  lungs;  .3  were  of  doubtful  origin. 

The  morbid  anatomy  of  the  S  rheumatic  cases  was  of  the  same  type. 
The  chief  features  were:  more  or  less  damage  of  the  heart  by  previous 
rheumatism  and  the  presence  of  vegetations  of  considerable  size  upon 
the  mitral  or  aortic  valves,  and  endocardium  of  the  left  auricle.  Infarc- 
tions were  found  in  the  kidneys,  spleen,  brain,  and  lungs,  l)ut  never 
anv  abscesses.  The  spleen  was  sometimes  much  enlarged  without  the 
pre.sence  of  any  visible  infarction. 

There  mav  be  nephritis,  the  condition  resembling  that  of  large  white 
kidnev.  In  3  cases  cerebral  hemorrhage  occurred  froin  infection  of  the 
cerebral  vessels,  and  in  1  an  enormous  aneurysm  of  the  right  common 
femoral  artery  developed. 

Symptomatology.  Clinical  Course. — The  course  of  the  illness  is 
usuailv  prolonged.  The  on.set  is  sometimes  gradual,  when  shortness  of 
breath,  ])recordial  pain,  and  anemia  are  often  the  first  warnings;  or  the 
illness  may  follow  upon  an  attack  of  rheumatism  with  vague  symptoms 
against  which  the  patient  has  struggled.  With  an  acute  onset  there  may 
be  shivering  and  vomiting.  The  temperature  is  irregular;  sometimes 
within  twenty-four  hours  the  range  is  considerable  (vide  chart,  Fig.  155); 
in  other  cases  there  is  a  constant  degree  of  pyrexia;  finally,  in  still  others, 
fever  occurs  at  irregular  intervals.  The  pulse  is  ray)id  and  the  heart 
is  excited,  and  there  is  often  a  loud  systolic  bruit  to  be  heard  over  the 
whole  precordium.  Progressive  anemia  is  generally  a  striking  feature, 
as  are  also  sudden  attacks  of  pain  associated  with  the  formation  of 
infarcts  in  the  different  organs.  Step  by  step  the  child  loses  ground, 
and  toward  the  close  of  life  is  delirious  at  nights.  The  wasting  is  pro- 
found, while  diarrhea  still  further  drains  the  patient's  strength. 

Purpura  and  increasing  breathlessness  from  the  anemia  and  gradual 


UNUSUAL    TYPES  OF  RHEUMATIC  HEART  DISEASE         723 


Fig. 155 


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724  DISEASES  OE    THE   IIEAUT  A.\D   BLOODVESSELS 

cardiac  failure  arc  warnings  t)f  tlic  end,  whicli  may  conic  suddenly 
from  cerebral  hemorrhage  or  syncope,  or  may  he  gradual  from  exhaus- 
tion of  the  child's  strength. 

Diagnosis. — In  the  early  stages  this  is  difiicult,  and  the  more  so 
because  there  are  transitional  forms;  these  are  cases  which  for  a  time 
show  malignant  symptoms,  hut  eventually  (juict  down  and  then  the  diag- 
nosis is  usually  thought  to  have  been  mistaken. 

Sometimes  there  is  doubt  at  first  whether  the  illness  is  not  typhoid 
fever,  tuberculosis,  pyemia,  or  malaria,  but  in  most  cases  in  childhood 
the  problem  is  this:  Are  we  dealing  with  a  severe  case  of  rheumatic 
carditis,  are  we  dealing  with  the  malignant  form  of  rheumatic  endo- 
carditis, or  are  we  tlealing  with  some  other  form  of  malignant  endo- 
carditis?   The  chief  diagnostic  points  of  malignant  endocarditis  are: 

1.  The  insidious  mode  of  onset,  with  the  early  signs  of  severe  injury 
to  the  heart.  2.  Anemia.  3.  Irregular  fever.  4.  A  persistently  excited 
action  of  the  heart,  with  a  loud  cardiac  murmur.  Alteration  of  the 
character  of  the  murmurs  has  not  appeared  to  me  of  real  value.  5. 
Enlargement  of  the  spleen.  6.  Evidences  of  infarction,  including 
purj)ura.  7.  Nephritis.  S.  The  occurrence  of  aneurysms  or  cerebral 
hemorrhage.     9.   Diarrhea. 

These  are  symptoms  which  point  to  the  malignant  type  of  endo- 
carditis. The  diagnosis  of  the  rheumatic  origin  is  confirmed  by  the 
isolation  of  the  diplococcus  from  the  blood  and  the  production  of 
experimental  rheumatic  fever  in  animals.  On  the  other  hand,  some 
cases  may  remain  doubtful  to  the  end,  for  it  is  rarely  that  one  can 
isolate  this  micro-organism  from  the  blood  during  life  in  these  ca,ses. 

Prognosis. — This  is  extremely  grave.  There  is  little  doubt  that  there 
are  cases  which  show  many  features  of  the  malignant  type  and  yet 
eventually  recover;  still  the  recovery  is  but  very  imperfect.  Those  cases 
which  are  unmistakai)ly  malignant  always  end  fatally. 

Treatment. — Treatment  is  exceedingly  imsatisfactory.  I  have  person- 
ally never  seen  any  good  result  from  the  use  of  antistreptococcic  or  other 
sera,  though  there  is  tnore  hope  in  this  direction  than  in  any  other.^ 

Every  cllort  should  be  made  to  maintain  the  strength  and  alleviate 
the  symptoms.  If  the  time  of  year  and  circumstances  permit,  I  prefer 
to  treat  these  cases  in  the  open  air.  Eying  on  a  couch  and  carefully 
guarded  against  draughts,  they  rest  quietly  in  a  pure  atmosphere  and 
are,  as  far  a.s  possible,  cautiously  fed  up.  The  princi])les  adopted  for 
tuberculosis  are,  in  a  modified  way,  applicable  to  these  patients  and 
have  the  same  end  in  view — viz.,  to  inc-rcase  the  resistance  of  the  body 
in  the  hope  of  mastering  the  infection. 

Acute  Rheumatic  Myocardial  Failure. — These  rare  cases  need  a  few 
lines  of  des(rij)ti()n.  The  effect  of  rheumatism  upon  the  myocardium 
has  been  already  dealt  witli;  this,  however,  is  a  condition  of  acute 
failure  whicli  deserves  special  mention. 

1  Since  writing  the  above  various  cases  have  been  recorded  in  which  serum  treatment  has  been 
thought  successful.  The  serum  that  has  been  used  has  generally  been  polyvalent  and  no  special 
antirheumatic  serum  has  been  employed. 


UNUSUAL   TYPES  OF  RHEUMATIC  HEART  DISEASE         725 

The  first  organ  attacked  may  be  the  heart,  but  in  some  cases,  at  least, 
arthritis  has  preceded.  The  chief  symptoms  are :  A  continued  moderate 
pyrexia,  a  rapid  pulse  (120  to  140),  and  rapid  respiration;  pain  over  the 
heart,  livid  pallor,  slight  edema,  restlessness,  and  vomiting  are  also 
usually  present;  fainting  attacks  are  liable  to  occur  and  death  may  be 
sudden  or  gradual,  with  complete  failure  of  the  pulse  at  the  wrist. 

Such  cases  will  remind  the  reader  of  the  acute  cardiac  failure  in 
diphtheria  (q.  v.). 

Diagnosis. — Diagnosis  rests  on  the  occurrence  of  rheumatism  and  the 
preponderating  evidence  of  myocardial  failure.  Antemortem  thrombosis 
may  complicate  the  condition. 

The  physical  signs  are  mostly  negative. 

The  impulse  is  diffuse  and  the  cardiac  area  enlarged  in  all  directions, 
but  there  is  no  evidence  of  pericarditis.  As  a  rule  there  is  a  soft  murmur, 
systolic  in  time,  audible  over  the  region  of  the  impulse;  this  is  some- 
times conducted  toward  the  axilla,  sometimes  not.  The  first  sound  is 
short  and  the  pulmonary  second  sound  accentuated  and  reduplicated. 
Thus  the  physician  discovers  dilatation  of  the  heart  with  grave  consti- 
tutional symptoms  and  infers  that  the  condition  is  one  of  acute  myo- 
cardial disease  the  result  of  rheumatism. 

The  course  of  the  illness  is  variable,  for  it  carries  with  it  the  danger 
of  sudden  death.  Should  the  illness  prove  fatal,  as  it  may  within  a 
week  from  the  development  of  the  severe  symptoms,  death  may  be 
quite  sudden.     These  very  acute  cases  are  generally  fatal, 

Treatment. — I  warn  against  the  use  of  salicylates  and  should  adopt 
the  same  methods  as  are  detailed  under  the  treatment  of  cardiac  failure 
due  to  diphtheria.     (See  page  743.) 

Multiple  Serositis. — Another  unusual  type  of  rheumatic  heart  disease 
is  that  with  which  there  is  associated  inflammation  of  other  serous 
membranes  in  addition  to  the  pericardial.  It  is  variously  named  indu- 
rative mediastinopericarditis,  or,  more  shortly,  multiple  serositis.  Rheu- 
matism is  not  the  only  cause;  tuberculosis,  scarlet  fever,  and,  possibly, 
syphilis  may  also  produce  the  condition.^ 

I  have  on  several  occasions  made  necropsies  upon  cases  of  rheumatic 
fever  in  children,  in  which,  in  addition  to  acute  pleurisy  and  peri- 
carditis, there  has  been  local  peritonitis  around  the  liver  and  spleen, 
and  once  during  life  have  heard  in  such  a  case  loud  peritoneal  friction. 
Three  times  with  Dr.  Paine  I  have  demonstrated  and  isolated  the 
micrococcus  from  the  peritoneal  exudation,  and  once  produced,  by 
intravenous  inoculation  of  a  rabbit,  peritonitis.  These,  it  is  true,  were 
acute  conditions,  but  they  clearly  have  a  bearing  upon  rheumatic 
multiple  serositis  and  afford  additional  evidence  in  favor^  of  its  occur- 
rence. ^^Tien  these  multiple  inflammations,  instead  of  being  acute,  are 
slow  and  smouldering,  then  the  clinical  picture  of  multiple  serositis 
will  appear. 

1  A  valuable  account  of  the  disease  has  been  recently  given  by  Dr.  A.  O,  J.  Kelly  in  the  Trans- 
actions of  the  College  of  Physicians  of  Philadelphia,  1902. 


726  DISEASES  OF    THE   HEART   AXD   BLOODVESSELS 

This  case,  for  which  I  am  iiulcbtrd  to  Dr.  F.  G.  Penrose,  will  give  a 
general  idea  of  the  type. 

A  l)ov,age(l  seven  and  a  half  years,  with  a  rheumatic  mother,  got  wet 
through  and  chilled.  A  week  afterward  he  develojjed  rheumatic  fever  and 
heart  disease.  Three  montlis  later  swelling  of  the  face  and  abdomen  was 
noticed.  The  boy  was  well  nourished,  with  a  fresh  complexion  and  in  no 
distress.  The  veins  in  the  neck  were  full.  The  cardiac  area  was  increased 
upward,  and  though  there  was  no  bruit,  the  sounds  were  mufHed,  and 
no  impulse  coukl  be  seen  or  felt.  The  air  entry  into  the  right  lung  was 
impaired,  and  the  percussion  note  dull  at  the  base.  The  urine  was 
natural,  there  was  no  edema  of  the  lower  extremities,  but  the  abdomen 
was  tense  with  fluid.  After  tapping,  a  large,  smooth  liver  was  detected. 
The  ascites  recm-red  and  he  h;is  needed  tapping  every  week  up  to  the 
time  of  writing.     Although  not  distressed  he  is  slowly  losing  ground. 

Ascites  was  clearly  the  prominent  symptom  in  this  case,  but,  as  Dr. 
Kellv  has  emphasized,  the  development  of  the  symptoms  differs  with 
the  particular  serous  membrane  which  is  first  affected.  I  think  it  is 
reasonal)le  to  expect  ascites  to  be  the  most  frequent  occurrence,  because 
the  pleural  and  pericartlial  sacs  may  be  obliterated,  but  not  so  the 
peritoneal,  which  has  to  bear  the  stress  of  chronic  inflammation  and 
cardiac  weakness.  The  course  of  the  illness  is  prolonged,  lasting  over 
many  months. 

Diagnosis. — Such  a  condition  is  puzzling,  for  the  original  illness  may 
be  ill-deflned  and  the  pericarditis  perhaps  overlooked.  Cirrhosis  of  the 
liver  and  tuberculous  peritonitis  are  easily  confused.  The  following 
points  are  of  assistance,  viz.,  the  evidences  of  an  adherent  pericardium, 
the  presence  of  pleuritis  or  an  adherent  ])leura,  the  occurrence  of  frecjuent 
attacks  of  pain  in  association  with  jx'rihepatitis,  and  the  discovery  of  a 
large,  smooth  liver.  Some  further  allusion  is  made  to  the  subject  under 
Tul)erculosis  of  the  Heart. 

Prognosis. — This  is  very  serious,  for  several  vital  organs  are  attacked. 
The  atlherent  pericardium  cripples  the  heart,  the  adherent  pleura  embar- 
rasses the  lung,  and  the  ascites  impairs  the  functions  of  all  the  intra- 
abdominal viscera.  Lastly,  the  repeated  ])araeentesis  undermines  the 
patient's  strength  by  drawing  away  gallons  of  albuminous  fluid.  Thus 
it  is  that  the  course  is  a  downhill  one. 

Treatment. — Treatment  is  palliative;  paracentesis  being  necessary 
when  there  is  much  discomfort,  or  when  the  fluid  in  the  abdomen 
embarrasses  the  action  of  the  heart  or  lungs. 


SOME  COMPLICATIONS  OF  RHEUMATIC  HEART  DISEASE. 

Infarction. — .Allusion  has  already  been  made,  under  ^Malignant  Rheu- 
matic iMidocarditis,  to  the  occurrence  of  infarctions.  These  may  also 
be  met  with  in  cases  which  are  looked  u|)()n  as  examples  of  simple 
rheumatic  endocarditis,  in  association  with  antemortem  thrombosis. 
This  thrombosis,  as  experiment  has  shown,  may  occur  from  myocardial 


COMPLICATIONS  OF  RHEUMATIC  HEART  DISEASE  727 

weakness  without  any  visible  endocarditis.  Infarctions  may  also  occur 
without  either  evident  antemortem  thrombosis  or  endocarditis.  Infarcts, 
then,  may  be  caused  by  bacterial  emboli  and  by  detached  fragments  of 
vegetations,  by  blood  clots  formed  in  the  ventricles  or  auricles,  and, 
lastly,  they  may  be  encouraged  by  the  increased  tendency  of  the  blood 
to  form  clots,  as  a  result  of  the  rheumatic  processes. 

No  detailed  description  of  the  morbid  changes  will  be  given,  but  it 
is  of  cardinal  importance  to  recognize  that  some  infarcts  contain  numer- 
ous bacteria,  while  others  contain  few  or  none  at  all. 

They  are  classified,  according  to  their  colors,  into  the  hemorrhagic 
or  red,  and  the  white.  In  rheumatism  they  may  soften,  but  do  not 
suppurate,  and,  as  a  rule,  the  necrotic  areas  in  the  tissues  heal  by  a 
process  of  scar  formation.  They  are  met  with  most  frequently  in  the 
Iddneys,  spleen,  lungs,  and  brain,  in  rare  instances  in  the  liver,  occa- 
sionally in  the  arteries,  and  I  have  once  seen  an  infarct  in  the  pancreas. 

Symptomatology. — Infarcts  may  occur  in  the  kidneys  and  produce 
little  disturbance ;  nevertheless  it  will  be  useful  to  give  some  indications — 
somewhat  arbitrary  ones,  perhaps — which  will  assist  the  diagnosis  of 
infarction : 

1.  Renal  Injarciion. — (a)  Sudden  pain  in  the  loins,  and  pyrexia. 
(h)  Sudden  hematuria  and  albuminuria,  and  the  passing  of  blood  and 
epithelial  casts  in  the  urine,     (c)  Tenderness  over  the  kidney. 

2.  Splenic  Infarction. — (a)  Sudden  pain  in  the  left  side,  and  pyrexia. 
(6)  Splenic  enlargement,  (e)  Splenic  tenderness,  {d)  Occasionally,  a 
friction  rub  over  the  splenic  area. 

3.  Pvlmonary  Infarction. — (a)  Sudden  pain  in  the  chest,  and  pyrexia. 
(6)  Cough,  dyspnea,  and  hemoptysis,  (c)  The  signs  of  an  area  of  solid 
lung  in  the  position  of  the  infarct  and  sometimes  pleural  friction  over 
that  same  area. 

4.  Cerebral  Infarction. — (a)  A  sudden  "stroke,"  with  or  without 
complete  loss  of  consciousness,  and  pyrexia,  (b)  Paralysis,  usually  of 
the  hemiplegic  type,  with  or  without  aphasia. 

5.  Infarction  m  the  Mesenteric  Vessels.- — (a)  Sudden  abdominal  pain, 
with  more  or  less  collapse,  (b)  Melena.  (c)  Meteorism,  and  sometimes 
peritonitis. 

The  occurrence  of  infarction  must  always  raise  the  suspicion  of 
malignant  endocarditis,  and  then  the  prognosis  is  very  gloomy.  Cerebral 
infarctions  are  the  most  dangerous ;  when  terminal  arteries  are  obstructed 
softening  of  the  brain  in  the  damaged  area  will  follow,  but  when  this 
is  not  the  case  there  may  be  good  recovery.  Infarcts  in  the  lungs, 
kidneys,  and  spleen  may  heal,  but  scarring  and  contraction  of  the 
damaged  areas  must  follow. 

Treatment. — The  great  indication  for  treatment  is  the  pain.  This  is 
eased  by  the  use  of  some  preparation  of  opium  and  external  applica- 
tions. 

Thrombosis  of  Veins. — This  is  a  rare  complication,  although  Schmidt, 
LetuUe,  Gatay,  and  other  French  writers  have  devoted  considerable 
attention  to  the  subject. 


728  DISEASES  OE    THE   HEART   A.\D    HLOODVESSELS 

One  of  these  eases,  a  «;;irl  at,a>il  nine  years,  is  briefly  quoted 
below : 

The  tjirl  was  a(hnitte(l  to  St.  Mary's  Hospital  under  Dr.  Cheadle, 
Fel)ruary,  1.S98,  with  advaneed  rheumatic  heart  disease,  followin<:;  an 
attack  (')f  scarlet  fever  two  years  previously.  She  was  a  child  of 
rheumatic  parentage.  Aortic  and  mitral  endocarditis,  and  pericarditis 
were  present,  with  edema,  cyanosis  and  nephritis.  The  occurrence  of 
rheumatic  nodules  stamped  the  c-ase  as  one  of  the  most  severe  type. 
In  March,  there  was  ])leurLsy  upon  the  right  side  and  after  this  some 
slight  imj)rovement.  In  A})ril,  the  thrond)Osis  conunencetl;  on  the 
13th  the  left  side  of  the  neck  swelled,  and  on  the  IGth  the  right  side.  The 
face  now  became  purple,  the  lips  and  eyelids  swollen,  the  neck  tense 
and  tender.  Her  temperature  was  subnornud.  On  the  17th  the  right 
arm  began  to  swell,  later  the  left  arm  and  the  upper  })art  of  th(>  chest. 
On  the  20th  two  firm  cords  were  felt  on  the  neck.  I)c>ath  occuired  on 
the  21st. 

The  necropsy  showed  antemortem  thrombosis  in  the  two  innominate, 
subclavian,  internal  and  external  jugulars,  and  axillary  veins  and  also 
in  the  inferior  thyroid  vein.  The  superior  vena  cava  was  filled  by  ante- 
mortem  thrombus  in  the  upper  two-thirds  of  its  extent. 

Six  examples  have  come  under  my  notice,  four  of  which  have  occurred 
in  children  suffering  from  advanced  rheumatic  heart  disease. 

Some  writers  mention  that  this  form  of  thrombosis  is  most  common 
in  the  lower  extremities,  but  all  the  cases  I  have  met  with  have  com- 
menced in  the  large  veins  at  the  root  of  the  neck,  thence  sometimes 
spreading  along  the  subclavian  and  axillary  vein,  at  other  times  spread- 
ing upward. 

Diagnosis. — Diagnosis  is  basiul  chiefly  on  the  local  appearance  and 
spread  of  the  edema,  the  tenderness  along  the  veins,  and  pain  on  move- 
ment of  the  affected  part,  and  the  dilatation  of  the  venous  tributaries 
which  supply  the  damaged  veins.  Fever  may  accompany  the  process, 
and  jK'techi.e  and  erythematous  patches  have  been  noted. 

Wlien  the  vein  is  felt  as  a  firm  cord,  the  diagnosis  is  certain.  In 
difficult  cases  the  swollen  face  of  renal  disease  and  parotitis  must  be 
excluded.  The  prognosis  in  such  cases  is  grave,  for  the  heart  disease 
is  often  severe,  and  there  are  also  the  added  dangers  of  a  clot  being 
detached  from  the  vein,  or  of  an  extension  of  the  ])rocess  of  thrombosis 
to  the  right  auricle. 

The  mild  cases,  and  those  in  which  the  condition  of  the  heart  is  not 
hopeless,  may  recover  completely  from  the  thrombosis. 

■^rhe  correct  explanation  of  the  occurrence  is  doubtful. 

It  is,  in  all  proi)ability,  an  active  rheumatic  process  and  not  merely 
the  result  of  a  failing  h(>art;  but  whether  there  is  a  primary  phlebitis  and 
a  secondary  formation  of  clot,  or  whether  the  thrombosis  is  the  primary 
change,  is  not  yet  clear. 

Treatment. — Treatment  is  palliative.  Pain  is  relieved  by  fomentations, 
and  by  giving  opium.  The  lind)  is  kept  at  rest,  and  the  movements  of 
the  neck  controlled,  so  far  as  it  is  possil>le  to  do  so.    When  all  the  acute 


COMPLICATIONS  OF   RHEUMATIC   HEART  DISEASE  729 

symptoms  have  passed  off,  and  if  the  hmb  still  remains  edematous, 
skilled  massage  is  helpful. 

Edema  of  the  Face. — One  peculiarity  of  the  heart  disease  of  childhood 
is  the  comparative  frequency  with  which  slight  edema  of  the  face  occurs. 
An  appearance  simulating  that  seen  in  renal  disease  is  the  result,  but 
without  any  of  the  changes  in  the  urine  usually  found  in  that  disease. 
Thrombosis  of  the  internal  jugulars,  as  already  described,  is  one  cause 
of  the  edema,  though  a  very  rare  one ;  another  is  indurative  mediastino- 
pericarditis,  and  a  third,  I  suspect,  is  some  slight  renal  damage. 

Pulmonary  Complications  of  Heart  Disease. — These  complications 
are  important  because  of  their  frequency  and  their  detrimental  influence 
upon  the  course  of  the  disease. 

Pleuropericarditis  and  Pleurisy. — These  are  usually  true  rheumatic 
manifestations.  Pleuropericarditis  is  detected  by  a  peculiar  physical 
sign,  the  pleuropericardial  friction  rub.  This  sign  is  heard  over  those 
regions  of  the  front  of  the  chest  which  correspond  to  the  positions  where 
the  lungs  overlap  the  heart.  The  peculiarity  of  the  sign  is  its  double 
rhythm;  not  only  is  it  synchronous  with  the  respiratory  movements,  but 
it  is  modified  also  by  the  cardiac  movements.  The  respiratory  rhythm 
is  the  more  superficial  and  the  more  striking,  so  that  the  cardiac  rhythm, 
which  is  the  fainter,  may  be  overlooked.  The  sign  is  an  important  one, 
because  pleurocardial  friction  may  be  present  without  necessarily 
inflammation  of  the  apposed  pericardial  surfaces,  and  thus,  although  a 
cause  of  pain  and  distress,  it  is  not  in  itself  a  danger  to  life. 

Rheumatic  pleurisy  is  a  frequent  occurrence.  The  exudation  is 
seldom  extensive  unless  there  is  in  addition  tricuspid  regurgitation,  and 
then  the  effusion  is  in  great  part  a  passive  one. 

It  is  a  cardinal  rule  of  treatment  to  deal  promptly  with  pleural  effusions 
when  they  complicate  heart  disease.  Early  paracentesis  is  required. 
The  important  indications  are:  distressing  shortness  of  breath,  trouble- 
some ineffectual  cough  with  blood-stained  expectoration,  and  absolute 
dulness  with  loss  of  breath  sounds  over  a  considerable  area  of  the  lungs 
at  one  or  both  bases.  As  the  heart  is  already  enlarged  by  disease,  it  is 
difficult  to  estimate  the  amount  that  it  has  been  displaced  by  the  effusion. 

Pneumonia. — Bronchopneumonia  is  one  of  the  manifestations  of  rheu- 
matic fever  and  in  the  worst  cases  of  rheumatic  carditis  is  a  great  danger. 
The  temperature  is  sometimes  unusually  high  (104°  F.)  for  a  case  of 
rheumatic  fever,  and  the  physical  signs  are  more  extensive  than  the  actual 
lesions  in  the  lung  would  lead  one  to  suspect.  This  condition  should  not 
be  confused  with  the  hypostatic  congestion  of  the  lower  lobes  of  the 
lungs  which  occurs  in  severe  tricuspid  regurgitation.  Rheumatic 
bronchopneumonia  may  occur  early  in  the  iflness;  the  symptoms  are 
acute  and  the  lesion  not  confined  to  the  bases  of  the  lungs. 

Edema  of  the  Lungs. — This  rare  complication,  of  which  I  have  seen 
three  examples,  is  most  hable  to  be  met  with  in  severe  carditis.  I  am 
not  sure  that  salicylate  of  soda  is  quite  free  from  blame  as  a  cause  of 
its  occurrence,  but  this  is  only  a  suspicion.  It  is  a  condition  comparable 
to  the  edema  of  renal  disease  and  begins,  as  does  that,  in  the  upper 


730  DISEASES  OF  Tin-:  iikaht  axd  bloodvessels 

1oIh\s  and  not  at  the  hasrs  of  tlu'  lini<,rs.  It  is  not,  then,  a  passive  edema 
due  to  slow  cardiac  failure. 

In  the  three  c-iuses  under  my  own  observation  one  ca.se  recovered  and 
the  other  two  died  in  twenty-four  hours,  'riie  indications  for  treatment 
are  free  stimulation  of  the  patient  and  the  inti-rdiction  of  all  depressin<; 
rejnedies. 

Other  Complications.  Purpura. — Purpura  when  it  complicates  heart 
disease  should  always  sugfjest  the  mali<jiumt  type  of  the  disease,  but  it 
mav  certainly  occur  with  simple  rheunuitic  carditis.  In  malignant 
cases  the  purpura  may  occur  in  all  tiie  serous  membranes  as  well  as  in 
the  skin. 

Nephritis  is  also  suggestive  of  malignant  rheumatic  heart  disease, 
for  it  is  onlv  the  graver  types  of  rheumatic  fever  which  so  injure  the 
kidnevs  as  to  give  rise  to  an  acute  nephritis.  'I'he  condition  nuist  be 
'distinguished  from  infarction,  which  is  sudden  in  onset  and  accompanied 
by  pain,  but  not  by  edema. 

Hyperpyrexia  and  Gangrene  of  the  extremities  are  both  very  rare 
complications. 


TREATMENT  OF  RHEUMATIC  HEART  DISEASE. 

The  treatment  of  rheumatic  heart  disease  is  not  satisfactory,  for 
although  much  may  be  done  to  palliate  the  condition  there  are,  at 
present,  no  means  of  arresting  the  scarring  consequent  upon  repair. 

Prophylaxis. — With  the  demonstration  of  the  infective  origin  of  rheu- 
matic fever  there  should  be  a  l)nght  future  for  prophylaxis.  The  logical 
step  is  to  deal  with  rheumatic  fever  as  with  any  other  great  infection, 
and  to  infjuire  closely  into  the  laws  that  govern  its  occurrence.  In  time 
this  forwanl  movement  must  be  made,  and  rheumatic  heart  disease  will 
become,  I  have  little  doubt,  less  frequent. 

There  are  clear  indications  to  re-examine  such  problems  as  the  influence 
of  crowded  towns,  damp  houses,  malsanitation,  and  the  influence  of  soil 
and  climate. 

So  far  as  the  child  of  rheumatic  parentage  is  concerned,  I  think  it 
very  advisable  that  a  close  inquiry  should  be  made  into  the  conditions 
of  the  place  of  residence.  It  should  l)e  thoroughly  dry,  and,  if  possible, 
a  clay  soil  is  best  avoided  aufl  a  gravel  one  chosen.  A  warm,  drv,  and 
equable  climate  is  the  best,  while  bleak  winds,  sultry  heats,  and  much 
du.st  are  detrimental.  It  is  not  likely  that  the  majority  of  these  children 
can  thus  be  accommodated,  but  it  is  well  to  })ear  in  mind  that  cold, 
damp,  and  crowded,  stuH'y  rooms  are  especially  to  l)e  avoided,  for  they 
lead  to  chills  and  sore  throats.  Damp  clothes  and  damp  l)eds  hardly 
need  a  mention,  except  to  emphasize  the  fact  that  errors  of  this  kind 
in  the  case  of  a  rheumatic  child  may  prove  fatal.  In  character  these 
children  are  often  umisually  bright,  ('motional,  and  energetic;  thev  tire 
their  boilies  before  they  tire  their  minds,  and  this  should  be  thoroughly 
recognized  by  the  parents.     Discipline,  enforced  rest  after  the  midday 


TREATMENT  OF  RHEUMATIC  HEART  DISEASE  731 

meal,  and  early  hours,  are  very  valuable  to  such  children,  more  especially 
when  they  are  becoming  nervous  and  thin. 

The  digestion  and  bowels  need  careful  supervision,  for  they  are  often 
disordered,  and  then  there  follow  night  terrors  and  insomnia,  urticaria, 
and  migrainous  headaches.  Such  ailments  should  be  treated  by  mild 
remedies.  The  old-fashioned  rhubarb  and  soda  mixture,  preceded  per- 
haps by  a  small  dose  of  calomel,  or  a  dose  of  compound  rhubarb 
powder  (Gregory's  powder),  which  is  best  given  with  a  little  sal  volatile, 
(ammonium  carbonate),  and  some  carbonate  of  magnesia  or  citrate  of 
potash  for  the  urticaria. 

For  deranged  digestion  with  constipation  the  following  is  useful: 

{fc— Pulv.  rhei 0.13  gm.  (2gr.) 

Sodii  bicarb 0.03  gm.  (5  gr.) 

Syr.  zingiberis 0.65  c.c.  (10  minims.) 

Aq.  menth.  pip q.  s.  ad      8.00  c.c.  (2  drachms.)— M. 

Sig. — Three  times  a  day  between  meals  for  a  child  of  seven  years. 

As  a  tonic,  quinine  or  the  alkaline  preparation  of  arsenic  may  be  given, 
or,  better  still,  a  change  of  air  is  recommended.  Strong  doses  of  iron 
or  large  doses  of  cod-liver  oil  usually  do  harm. 

The  gums  and  teeth  should  be  looked  after  and  the  development  of  a 
chronic  gingivitis  from  decayed  teeth  thus  prevented. 

As  a  general  tonic,  the  following  is  recommended: 

T^ — Liq.  arsenioalis 0.13  c.c.  (2  minims.) 

Tinct.  nucis  vomicEe,  B.  P. 0.20  c.c.  (3  minims.) 

Syr.  aurant.  cort 1.30  c.c.  (20  minims.) 

Aq.  chloroformi q.s.  ad  8.00  c.c.  (2 drachms.) — M. 

Sig. — Three  times  a  day  after  meals  for  a  child  of  seven. 

The  throat  will  need  especial  care,  for  one  certain  path  of  invasion  is 
by  way  of  the  tonsils.  I  teach  rheumatic  children  to  learn  to  gargle 
early  in  life,  at  first  with  plain  water,  and  later  with  a  gargle  of  borax, 
oxymel,  and  rose-water.  It  is  a  great  mistake,  I  believe,  to  force  these 
children  with  much  study;  and  public  schools  of  American  cities  and  the 
board  schools  of  England  with  their  medals  and  enforced  attendances 
are  responsible  for  a  good  deal  of  chorea  and  heart  disease.  The  resist- 
ance of  the  child  is  lowered,  and  then  follows  a  sore  throat,  with 
rheumatic  heart  disease. 

The  diet  should  be  plain  and  varied,  and  there  is  no  objection  to  the 
giving  of  butchers'  meat  in  a  limited  amount,  say  once  a  day. 

Warm  clothing  is  very  necessary;  woollen  undergarments  for  winter 
and  the  best  quality  of  interwoven  wool  and  silk  for  summer;  good  boots 
and  warm  socks  and  stockings  must  be  insisted  upon.  There  is  always 
this  hope  to  stimulate  us,  that  if  we  can  tide  the  rheumatic  child  over  his 
youth,  he  will  become  later  in  life  less  susceptible  to  cardiac  rheumatism. 

Acute  and  Subacute  Carditis.  Medicinal  Treatment. — The  most 
successful  method  of  treatment  of  the  acute  phases  of  rheumatic 
carditis  is  a  debated  question,  and  at  the  present  time  the  use  of 
salicylates,  in  some  form  or  another,  has  taken  such  a  hold  on  the 
medical  profession  that  it  will  be  advisable  to  comment  upon  it  before 
turning  to  the  general  measures. 


732  DISEASES  OF   THE   HEART   AXD   BLOODVESSELS 

Allowing  that  salicylate  of  soda  is  an  antidote,  can  it  be  safely  given 
in  large  doses?  These  are  necessary,  for  even  the  advocates  of  the 
specific  action  admit  that  large  doses  arc  needful  to  control  cardiac 
rheumatism. 

My  own  answer  is  in  the  negative.  I  do  not  think  it  is  a  direct  antidote 
for  cardiac  rheumatLsm  or  that  it  can  be  given  in  large  doses  to  children 
without  consitlerable  risk.  I  cannot  accept  the  statement,  and  it  seems 
to  me  onlv  a  statement  that  salicylate  compounds  are  a  direct  antidote 
to  rhcunuitism.  It  is  very  doubtful  that  a  disea.se  such  a.s  rheumatic 
fever  forms  only  one  poison;  indeed,  such  evidence  a.s  there  is  points  to 
it  forming  many;  nor  do  I  think  that  in  the  ti.ssues  the  salicylate  com- 
pounds have  much  antibacterial  effect,  for  active  rheumatic  lesions  can 
develop,  even  when  large  doses  are  given. 

In  rheumatic  heart  disease  there  is  no  doui)t  that  the  articular  pains 
are  greatly  relieved  and  the  temperature  lowered  by  this  treatment,  but 
the  articular  pain.s — important  though  they  are — are  only  an  incident, 
antl  the  fever  is  very  rarely  a  real  danger.  On  the  other  hand,  small 
doses  do  not  seem  to  do  harm,  and  certainly  relieve  the  articular  pains. 

The  risks  are  an  idiosyncrasy  which  may  show  itself  after  a  very  few 
large  doses  of  the  drug,  in  severe  vomiting,  great  flepression,  and  general 
illness.  As  I  pointed  out  in  the  article  on  rheumatic  fever  in  the  Encyclo- 
pcedia  Medica,  1901,  it  may  also  cause  a  curious  condition  of  dyspnea 
resembling  tliat  seen  in  diai)etic  coma.  It  is  also  a  cardiac  depressant 
and,  as  it  produces  polyuria,  is  possibly  an  irritant  to  the  kidneys. 

It  does  not  seem  to  me  that  the  cases  treated  by  large  doses  of 
salicylate  of  soda  do  better  than  others,  but  rather  do  worse,  for  alarms 
from  the  effect  of  the  drug  are  apt  to  arise  and  are  added  to  the  natural 
anxieties  of  the  disease;  nor  are  cases  so  treated  protected  from  relapses. 

At  the  present  time  there  appears  to  me  no  good  reason  for  adopting 
more  than  mild  and  palliative  measures  in  acute  rheumatic  heart  dis- 
ease. Possibly  in  the  future  it  may  be  necessary  to  withdraw  this  state- 
ment, and  I  would  do  so  willingly  now  if  I  could  see  any  decisive  evidence 
in  favor  of  a  sju'cific  treatment. 

The  Palliative  Management. — With  this  method  the  physician  con- 
fe.s.ses  that  there  is  no  medicine  with  a  directly  curative  action,  but,  keep- 
ing before  him  the  great  natural  resistance  there  is  to  the  rheumatic 
infection  and  the  danger  of  interfering  with  such  V)y  powerful  and 
possibly  useless  or  even  harmful  remedies,  he  endeavors  to  aid  the 
natural  resistance  in  every  possible  way. 

A  good  example  to  take  of  acute  heart  disease  is  acute  pericarditis 
with  mitral  endocarditis. 

Rest  is  imperative,  and  the  child  should  be  kept  lying  down,  unless 
there  is  difficulty  in  breathing  when  in  that  position.  There  is  not  the 
same  need  for  tlie  wrapping  in  blankets  as  in  adults,  for  these  children 
rarely  sweat  at  all  freely.  The  food  should  be  licpiid  and  consist  chiefly 
of  milk  diluted  with  water  or  barley-water.  Beef-tea  and  chicken-broth 
may  be  given,  and  if  the  appetite  is  good  and  the  temjjcrature  but  little 
raised,  a  more  lil)eral  diet  allowed,  such  as  an  egg  or  a  little  fish,  well- 


TREATMENT  OF  RHEUMATIC  HEART  DISEASE  733 

made  bread  and  milk,  jellies,  and  the  like.  Severe  cases  need  very  careful 
feeding  with  peptonized  milk  or  thin  gruels  every  two  hours  in  the  day 
and  every  three  hours  at  night,  but  less  severe  cases  may,  I  think,  be  fed 
more  liberally  with  advantage. 

Stimulants  are  valuable  when  there  are  pallor  and  restlessness,  and 
when  the  pulse  is  flagging  and  rapid,  and  the  desire  for  food  failing. 
\\'Tien  patients  have  been  allowed  to  walk  about  before  being  seen  by  a 
physician  they  are  often  found  quite  exhausted.  Rest  and  some  brandy 
will  then  work  wonders.  A  mild  case  of  rheumatic  heart  disease  does 
not  need  stimulants;  these  should  be  given  in  bad  cases  only,  and  for  a 
definite  purpose.  For  a  child  of  seven  15  to  23  c.c.  (S^  to  Sf)  of 
brandy  will  be  usually  sufficient  in  the  twenty-four  hours.  Much  is 
written  of  the  detrimental  efl^ect  of  alcohol  upon  the  cardiac  muscle,  but, 
used  for  a  short  time  of  need,  it  seems  impossible  that  it  can  do  any 
harm,  and  that  it  aids  sleep  and  digestion  in  these  cases  is,  I  believe, 
undoubted.     H}T>erp}Texia  is  nearly  unknown  at  this  early  age. 

Arthritis  is  one  of  the  most  common  of  the  definite  sjnnptoms.  Besides 
bandaging  the  joints  lightly,  salicylates  of  soda  in  doses  of  0.  32-0.65  gm. 
(5  to  10  gr.),  in  water  flavored  with  orange,  every  three  hours  is  effective 
in  relieving  the  pains. 

Salicin  or  aspirin  may  be  used  in  similar  doses  for  weakly  children, 
but  I  have  found  no  great  advantage  in  aspirin,  which  is  best  administered 
as 

{fc — Aspirin 0.3  gm.       (5  grains.) 

Pulv.  tragacanth.  comp q.  s. 

Aq.  chloroformi q.  s.  ad      8.0  c.c.        (2  drachms.) — M. 

Sig. — For  a  ciiild  of  seven  years  2  teaspoonfuls  (8  c.c.)  every  four  hours. 

Nothing  seems  to  ea.se  the  pain  of  pericarditis  more  effectually  than 
an  ice-bag,  and  the  steady  advocacy  of  this  by  Dr.  D.  B.  Lees  has  done 
good  service.  It  serves  the  additional  purpose  of  keeping  the  child 
quiet  and  it  is  usually  well  borne,  though  I  do  not  advise  it  when  the 
t}^e  of  the  illness  is  asthenic,  and  the  temperature  normal  or  sub- 
normal. The  physicians  should  give  strict  injunctions  as  to  its  use,  and 
it  mu.st  be  removed  if  the  temperature  falls  rapidly  and  there  is  any  sign 
of  collapse.  The  assistance  of  trained  nurses  in  a  case  of  severe  peri- 
carditis is  extremely  useful.  If  the  chest  is  tender,  the  bag  must  be 
suspended,  and 'it  can  be  wtII  fixed  by  passing  the  neck  of  the  ice-bag 
through  a  hole  in  the  flannel  under  the  vest;  it  must  not  leak,  and  the 
ice  should  be  carefully  pounded.  Its  constant  application  is  the  most 
satisfactory,  and  for  the  first  twelve  hours  the  temperature  should  be 
taken  every  two  hours,  but  after  this  at  longer  intervals.  That  it  has 
any  curative  action  I  am  doubtful;  nevertheless  the  pain  is  relieved  and 
the  heart  quieted. 

Hot-water  bottles  should  be  placed  near  the  lower  extremities  while 
the  ice  is  in  use. 

For  acute  pericarditis  I  do  not  advise  bleeding,  except  in  rare  cases 
where  there  is  some  chronic  valvular  lesion  which  has  embarrassed  the 
right  heart  and  threatens  its  arrest  from  overdistention.  This  indication 
will  be  considered  later. 


734  DISEASES  OF   THE   HEART   AMJ   BLOODVESSELS 

Ijccclies  to  the  ])rec'()rdiiun  are  indicatod  when  dyspnea  is  ur^jent,  and 
four  are  usnally  suffieient.  Blisters  hurt  ehihhvn,  and,  besides,  I  do  not 
think  tliey  do  any  real  <;()o(l  in  acnte  j)eriearditis. 

The  bowels  should  be  opened  at  first  with  a  small  dos(>  of  ealoniel, 
1  to  2  gr.  (0.065  to  0.13  gm.),  to  be  followed  by  a  morning  dose  of  sul- 
phate of  magnesia  and  sul})hate  of  soda.  During  the  illness  strong 
purging  is  harmful,  easeara  or  liquorice  powder  usually  sufheing. 

For  restlessness  and  insomnia  opium  is  invaluable,  and  nej)enthe 
combined  with  some  potassium  bromide  may  gain  a  night's  rest  for 
the  patient,  which  is  of  the  utmost  value. 

^ — Nepenthe 4  minims  (0  15  c.c.) 

Potas.  broraidi 5  grains  (0.3  gm.) 

Glycerini 20niiiiiin.s        (1.3  c.c.) 

Aq.  chloroformi q.  s.  ad        'idraclinis       («.00c.c.) — M. 

Sig  — Twoteasiwonfuls  (8  c.c)  at  niglit.to  be  repeated  if  uece.ssary,  fur  a  cliild  of  seven  years. 

Another  n.seful  drug  is  chloralann'de,  10  gr.  (0.G5  gm.)  of  the  powder 
di.s.solved  in  two  teaspoonfuls  of  brandy  and  diluted  to  suit  the  taste 
with  water. 

If  there  is  rea.son  to  believc>  that  a  considerable  jHMicardial  ett"usion 
is  present,  digitalis  is  not  .safe,  but  if  there  is  dilatation  and  the  action 
of  the  heart  is  raj)id  and  excited  it  is  indicated  in  small  doses  given  both 
day  and  night.  Neither  this  drug  nor  strychnine  should  be  left  off  sud- 
denly if  it  can  possibly  l)e  avoided,  for  the  heart  feels  the  sudden 
loss,  and  collap.se  may  follow. 

9; — Tlnct.  digitalis,  B.I'. 5  minims        (0.3  c.c.) 

Glycerini 15  minims       (1.0  c.c.) 

Infus  aurantii q.s.  ad        2  drachms       (8.0  c.c.) — M. 

Sig. — Two  teaspoonfuls  (8  c.c.)  every  four  hours  for  a  child  of  seven  yeare. 

Strychnine  is  much  used,  but  I  would  repeat  the  valuable  warning 
given  by  Dr.  Cheadle  against  its  use,  either  when  the  heart  is  excited 
or  at  a  too  early  date  in  the  illness.  Overstimulation  of  an  excited 
heart  and  premature  stimulation  of  a  diseased  one  are  serious  errors 
of  treatment. 

I;t     Liq.  strychninie,  B.  P 2minims        (0.12c.c) 

Sp.  chloroformi 2  minims        (0.12  c.c.) 

Infus.  aurantii q.  s.  ad        2 drachms     (S.OOc.C.)— M. 

Sig. — Two  teaspoonfuls  (8  c.c.)  every  si.\  hours  for  a  child  of  seven  years. 

The  drug  is,  T  think,  best  given  at  first  by  the  mouth  and  later  hypo- 
dermically,  every  six  hours. 

In  sudden  collap.se  from  acute  heart  failure  the  hyjiodermic  method 
is  mo.st  valuable,  and  at  such  a  crisis  a  mixture  of  ammonia  and  ether 
is  useful  as  a  powerful  .stimulant,  and  can  be  given  every  two  hours  for 
tiiree  or  four  do.ses. 

Dilatation  of  the  stomach  and  vomiting  may  add  to  the  difficulties 
of  treatment;  if  they  occur  it  is  very  necessary  to  decide  whether  it  is 
the  method  of  feeding,  the  medicine,  or  the  cardiac  failure  that  is  the 
most  to  blame.  In  any  ca.se  prom])t  treatment  is  needed.  Milk  should 
be  peptonized,   or  less   should    be  gi\en;  concentrated  meat  essences 


TREATMENT  OF   RHEUMATIC   HEART  DISEASE  735 

in  teaspoonful  doses  will  sometimes  arrest  vomiting  if  all  other  food  is 
stopped  for  twelve  hours.  In  the  worst  cases  nutrient  enemata  must 
be  relied  upon. 

Bismuth  is  indicated  when  there  is  irritability  of  the  gastric  mucous 
membrane  from  enfeebled  circulation;  it  is  best  given  as  the  sub- 
carbonate  and  in  large  doses,  bismuthi  subcarbonatLs,  0.65  to  1.0  gm. 
(10  to  15  gr.),  combined,  if  necessary,  with  nepenthe.  Salicylate  of  soda 
and  digitalis  may  both  cause  vomiting,  but  the  former  very  rarely  does  so 
in  the  small  doses  advocated  for  the  arthritis.  If  the  digitalis  causes 
vomiting,  it  is  well  to  leave  it  off  and  to  substitute  caffeine. 

Jk— Caffein 0.2  gm.        (3  grains.) 

Spirit,  camphorae 0.3  c.c.        (5  minims.) 

Mucilaginis  acaciae  1.3  c.c.        (20  minims.) 

Aquae  chloroformi q.  s.  ad       8.0  c.c.        (2  drachms.)— M. 

Sig. — Two  teaspoonfuls  (8  c.c.)  every  six  hours  lor  a  child  of  seven  years. 

Pulmonary  complications  must  be  treated  upon  the  lines  laid  down 
in  the  article  dealing  with  Respiratory  Diseases  (q.  v.).  It  is  important, 
however,  to  bear  in  mind  that  pleural  effusions  must  be  tapped  early  in 
all  cases  of  heart  disease 

Many  a  case  of  pericarditis  runs  its  whole  course  without  any  indi- 
cation for  very  special  measures;  in  such  cases  quinine  given  in  tonic 
doses  is  a  useful  routine  prescription. 

Sometimes  it  seems  to  me  considerable  harm  is  done  to  a  child  by 
continually  worrying  it  with  medicine,  food,  temperature  taking, 
stimulants,  and  what  not;  the  child  never  has  a  quiet  moment,  for  if 
there  is  nothing  else  to  be  done  his  pillow  is  shaken  or  the  quilt  put 
straight.  Rather  than  this,  I  would  prefer  to  give  no  medicines  at  all, 
but  to  trust  that  under  the  influence  of  regular  feeding,  a  comfortable 
and  warm  bed  and  peaceful  moments,  liLs  leukocjiies  will  quietly  destroy 
the  micro-organisms. 

The  convalescence  after  carditis  is  prolonged,  so  that  the  key-note 
in  the  management  of  the  patient  should  be  caution.  There  are  no 
hard  and  fa.st  rules  to  be  followed,  Ijut  a  continued  normal  temperature, 
the  absence  of  rheumatic  symptoms,  the  improvement  in  the  pulse, 
and  the  diminution  in  the  size  of  the  heart  are  important  guides.  The 
cardiac  tonics  should  be  gradually  withdrawn,  and  be  replaced  by 
quinine  or  salicylate  of  cjuinine,  or  a  little  arsenic  in  alkaline  solution 
given  as  general  tonics,  and  the  following  are  suggested  : 

^ — Rheumatin 0.2  gm.        (3  grains.) 

Pulv.  tragacanth.  comp q.  s. 

Aq.  chloroformi q.  s.  ad        8.0  c.c         (2  drachms.  )—M. 

Sig. — Two  teaspoonfuls  (8  c.c.)  three  times  a  day  after  meals  for  a  child  of  seven. 

Jfc — Ferri  et  ammonii  citrati 0.3  gm.        (5  grains.) 

Liq.  arsenicali 0.2  c.c.        (3  minims.) 

Glycerini 1 3  c.c.        (20  minims.) 

Aq.  chlorof. q.  s.  ad       8.0  c.c.        (2  drachms.) — M. 

Sig. — Two  teaspoonfuls  (8  c.c.)  three  times  a  day  after  meals  for  a  child  of  seven. 

Some  care  is  required  in  prescribing  iron  for  the  anemia,  because  the 
digestion  is  easily  disturbed;  the  alkaline  preparations,  however,  can 
be  given  with  success. 


736  DISKASKS  OF    THE   llF.MiT   AM)   JilJXJDVlJSSELS 

Sitting  u]),  K^'ttiiifj;  oil  to  a  couch,  putting  the  feet  tlown— hi  a  word, 
each  forward  stc])  will  be  gauged.  Above  all  let  me  utter  a  warning 
ao-ainst  the  sudden  dismissal  of  a  rheumatic  child  from  a  hospital 
to  return  to  a  poor  home,  for  the  purpose  of  getting  an  empty  cot. 

The  use  of  passive  movements  for  bridging  over  the  wide  gap  between 
complete  rest  and  voluntary  movement  is  of  great  practical  value. 

For  the  well-to-do,  it  is  advisable,  as  soon  as  the  journey  can  be 
undertaken,  to  remove  the  child  to  a  warm,  sunny,  dry  climate,  pref- 
erably inland,  where  he  can  lie  flat  on  a  couch  out-of-doors  for  hours, 
or  be  wheeled  about  in  the  fresh  air.  Drugs,  such  as  arsenic  and  iron, 
can  then  be  given  up.  There  seem  to  me  to  be  the  same  indications 
for  the  liberal  feeding  of  the  convalescent  in  this  disease  as  there  are 
for  the  lil)eral  feeding  of  the  convalescent  from  tuberculosis. 

It  is  wonderful  what  a  stimulus  a  change  of  scene  and  air  may  be 
to  the  invalid  whom  an  overcautious  treatment  has  kept  stagnant  in 
one  room.  True  enough  of  the  adult,  it  is  doubly  true  of  the  child, 
provided,  always,  that  it  is  not  agitated  by  many  visitors  and  exciting 
books,  or,  as  is  so  often  the  case  with  rheumatic  children,  by  higlily 
nervous  parents. 

When  walking  can  be  undertaken,  the  same  cautious  forward  policy 
should  be  pursued.  At  first  the  child  should  have  steady  exercise  on 
the  level,  then  later  up  gentle  inclines,  the  ordered  passive  movements 
now  giving  place  to  ordered  voluntiiry  movements;  in  this  way  the 
cardiac  muscle  is  strengthened.  The  care  and  time  over  such  details 
are  well  spent.  Some  philanthropist  should  found  homes  for  the  children 
of  the  poor  suffering  from  rheumatic  affections  of  the  heart,  where, 
during  convalescence,  treatment  on  these  liiu'S  could  l)e  carried  out. 

The  Salicylate  Treatment  of  Acute  Rheumatic  Heart  Disease. — This 
method  has  l)een  recently  detailetl  by  Dr.  1).  B.  Lees,  of  London.  It  is 
in  principle  the  antithesis  of  the  palliative  method,  and  claims  to  be 
specific. 

Dr.  Ijccs  points  out  that,  occasionally,  ill  effects  may  arise  from  the 
use  of  the  drug,  l)ut  believes  these  to  be  rare.  The  occurrence  of  air 
hunger,  he  thinks,  may  be  explained  by  the  action  of  excess  of  acid 
upon  the  respiratory  centre,  and  this  he  counteracts  by  the  combination 
of  double  the  dose  of  bicarbonate  of  sodium  with  the  salicylate  of 
sodium.  The  dej)ressant  action  of  the  drug  is,  in  his  opinion,  greatly 
exaggerated.  Should  there  be  intolerance,  after  suspension  of  the  drug 
for  a  few  hours,  it  should  be  recommenced  in  small  doses  and  then 
progressively  increased . 

For  a  child  from  six  to  ten  years  of  age  O.^o  gm.  HO  gr.)  of  salicylate 
of  soda  and  L.'^  gm.  (20  gr.)  of  Ijicarbonate  of  sodium  are  given  every 
two  hours  during  the  day  and  every  four  hours  during  the  night;  after 
a  day  or  two  these  doses  may  be  increased  to  1  gm.  (15  gr.)  and  2  gm. 
(30  gr.),  respectively,  and  later  to  L3  gm.  (20  gr.)  and  2.65  gm.  (40  gr.). 

The  treatment  should  be  persisted  in  through  the  attack,  and  only 
stopped  when  all  the  active  symptoms  have  abated,  and  then  gradually 
relinquished. 


TREATMENT  OF  RHEUMATIC  HEART  DISEASE  737 

In  addition  to  this,  for  reducing  the  cardiac  inflammation,  an  ice-bag 
is  applied  to  the  precordium,  and  if  on  careful  percussion  of  the  deep 
cardiac  dulness  the  right  auricle  is  found  distended,  leeches  are  applied 
below  the  right  nipple,  preferably  before  the  ice-bag  is  used. 

Dr.  Lees  maintains  {Harveian  Lectures,  1903)  that  treatment  of  this 
kind  "greatly  diminishes  the  tendency  to  rheumatic  relapse,  checks 
the  inflammation,  increases  the  vigor  of  the  muscular  fibre,  and  dimin- 
ishes the  dilatation,  thus  enormously  assisting  the  forces  that  make 
for  repair." 

Treatment  of  Chronic  Heart  Disease.  ^When  the  lesion  is  compen- 
sated, the  treatment  resolves  itself  into  a  discrete  study  of  the  general 
health  and  careful  superintendence  of  the  active  pursuits.  When 
compensation  is  failing,  rest  in  bed  is  the  first  indication,  and  that 
alone  may  be  sufficient  without  any  further  treatment.  The  failure, 
however,  may  be  acute,  and  in  mitral  disease  the  right  side  of  the 
heart,  hampered  by  overdistention,  may  threaten  to  fail  entirely. 
Again,  when  there  is  well-marked  tricuspid  regurgitation,  the  functions 
of  all  the  organs,  and  especially  the  abdominal,  are  interfered  with  by 
the  congestion  of  the  venous  system.  These,  then,  are  both  of  them 
important  indications  for  a  treatment  more  drastic  than  that  of  rest. 

^^^len  the  pulse  at  the  wrist  is  small,  the  child  blue  and  dyspneic, 
the  cardiac  enlargement  to  the  right  of  the  sternum  much  increased, 
and  the  epigastric  pulsation  forcible,  it  is  necessary  to  abstract  blood 
in  one  way  or  another.  The  more  usual  method  is  to  place  four  to  six 
leeches  over  the  tender  liver,  and  afterward  to  let  the  leech-bites  bleed 
or  not,  as  may  be  thought  fit.  Sometimes,  even  in  children,  the  urgency 
is  extreme  and  then  the  median  basilic  or  external  jugular  vein  should 
be  opened  with  a  lancet.  It  is  a  cardinal  rule  that  children  bear  loss 
of  blood  badly,  but,  in  such  crises,  they  bear  overdistention  of  the 
right  side  of  the  heart  still  worse.  The  withdrawal  of  four  to  six  ounces 
will  suffice.  ^Mien  the  blood  has  been  abstracted,  the  relief  obtained 
is  very  striking;  but  no  time  should  be  lost  in  rousing  the  heart  to  more 
vigorous  action.  Strychnine  should  be  administered  hypodermically  or 
by  the  mouth,  and  when  the  mitral  regurgitant  lesion  is  the  chief  lesion, 
digitalis,  also,  should  be  given  every  three  hours  until  the  heart  has 
rallied.  Stimulants  are  needed,  and  the  extremities  must  be  kept 
warm.  \^T:ien  the  heart  has  recovered  it  is  not  advisable  to  keep  up 
this  strong  stimulation,  but  by  degrees  to  lessen  it  to  a  gentle  tonic 
action. 

The  general  congestion  of  the  viscera  in  the  less  severe  cases  depends 
primarily  upon  the  heart-failure,  and  when  this  condition  improves 
the  congestion  lessens.  It  is,  however,  a  difficulty  and  danger  in  itself, 
and  as  such  needs  treatment.  The  hepatic  functions  are  sluggish;  the 
stomach  is  dilated  and  its  mucous  membrane  catarrhal;  the  kidneys 
excrete  with  difficulty  a  scanty  and  sometimes  albuminous  urine; 
further,  the  lungs  are  congested  at  their  bases.  Vomiting,  nausea, 
dyspnea  and  insomnia  greatly  add  to  the  distress  and  militate  against 
recovery.  It  is  well,  then,  to  ease  the  liver  by  a  dose  of  calomel  followed 
47 


738  DISEASES  OF    THE   HEART   A\D   BLOODVESSELS 

1)V  a  .saliiH-  piirp',  and  it  is  a  .sound  riik-  in  practice'  to  do  this  hpfore 
ijiviiig  a  drug  such  as  digitalis,  which  readily  deranges  the  digestion. 
Bismuth  and  soda  may  be  required  to  soothe  the  mucous  membrane  of 
the  stomach;  and  it  may  l)e  necessary  when  there  is  a  tendency  to  vomit, 
cither  to  give  small  (juantities  of  ])eptonized  milk  alternately  with  a 
little  meat  juice,  or  even  to  stop  food  by  the  mouth  altogether. 

Insomnia  needs  prompt  treatment;  trional,  chloralamide,  bromide  of 
sodium  or  potassium  may  be  sufficient,  and  if  there  is  no  marked  cyanosis 
or  renal  congestion  opium  may  be  used  very  successfully,  either  alone 
or  combined  with  the  bromide.  In  the  mean  time  rest  and  cardiac 
tonics  should,  in  a  favorable  case,  be  aiding  the  heart,  and  in  this  way 
the  child  may  be  brought  to  a  condition  of  comparative  comfort  from 
ouv  of  great  distress. 

Treatment  of  Severe  Attacks  of  Palpitation  with  Precordial  Pain. — In 
some  cases  of  mitral  stenosis  there  may  be  most  distressing  attacks  of 
pain  and  palpitation,  which  are  probably  due  to  acute  overdistention 
of  the  right  side  of  the  heart.  This  eondition  may  be  relieved  by  bleed- 
ing, but  there  is  often  need  in  addition  for  some  medicinal  treatment 
to  relieve  the  anguish.  Inhalation  of  nitrite  of  amyl  is  sometimes  of 
service,  while  in  other  cases  a  combination  of  atropine  antl  strychnine, 
injected  under  the  skin  or  given  by  the  mouth,  is  the  most  effectual 
remedy. 

9:— Liq.  strj'chninse,  B.  P 

Liq.  atropinjesalphatis,  B.  P 

Syrupi  aurantii 

Aqusc  chloroformi ad 

Sig.— Two  teaspoonfuls  (8  c.c.)  at  once. 

There  is  considerable  risk  in  giving  morjihine  in  such  a  condition, 
for  there  is  often  a  period  of  shock  noticed  immediately  after  a  hypo- 
dermic injection  of  that  drug;  death  may  occur  iluring  this  period, 
before  the  soothing  effect  of  the  morphine  has  time  to  take  effect. 

Bromide  of  potassium  is  ineffectual.  Useful  enough  for  the  purpose 
of  soothing  the  state  of  nervousness  which  necessarily  follows  such  an 
attack,  it  is  too  slow  in  its  action,  and  too  feeble  in  its  power  to  alleviate 
])ain  and  to  cope  with  the  urgency  of  this  symptom. 

Anasarca. — Although  such  cases  are  imcommon,  yet,  now  and  again, 
a  child  may  become  very  edematous,  and  this  edema  will  necessitate 
some  treatment.  The  liquids  in  the  diet  should  then  be  diminished  as 
much  as  is  possible,  without  causing  distress.  Digitalis  is  often  of 
much  use.  The  lower  extremities  can  be  drained  by  means  of  Southey's 
tulx's,  introfluced  with  every  precaution  against  septic  infection. 

When  there  is  ascites,  paracentesis  should  not  l)e  delayed  if  there  is 
discomfort  from  the  flistention,  embarrassment  of  the  action  of  the  heart, 
difficulty  in  respiration  from  upward  pressure  upon  the  bases  of  the 
lungs,  or  diminution  in  the  secretion  of  urine.  The  fluid  should  be 
slowly  withdrawn,  and  the  abdominal  wall  supyH)rted  l)y  a  many-tailed 
binder,  which  is  gradually  tightened  as  the  fluid  is  withdrawn. 

This  general  rule  can  be  formulated  for  the  use  of  digitalis  in  the 


0.06  C.C. 

(1  minim.) 

0.06  c.c. 

(1  minim.) 

0  60  C.C. 

(10  minims.) 

8.00  c.c. 

(2  drachms.)— M. 

TREATMENT  OF  RHEUMATIC   HEART  DISEASE  739 

heart  disease  of  childhood :  It  must  be  given  with  great  caution,  if  at  all, 
when  there  is  good  reason  to  believe  the  cardiac  muscle  is  greatly 
damaged,  or  when  the  muscular  contractions  are  impeded  by  a  large 
pericardial  effusion. 

Serum  Treatment. — The  common  belief  that  rheumatic  fever  is  an 
attenuated  pyemia  has  led  to  the  use  of  antistreptococcic  serum  in  the 
treatment  of  rheumatic  heart  disease.  This  method  I  have  tried  in 
carefully  chosen  cases,  but  without  any  success. 

An  antibacterial  serum  such  as  the  antistreptococcic  is  not  at  present 
a  satisfactory  remedy,  and  I  would  warn  the  practitioner  against  the 
assumption  that  it  is  necessarily  innocuous,  even  if  it  is  not  useful. 
Menzer  has  recently  introduced  a  special  serum,  but,  not  having  any 
experience  of  its  use,  I  would  refer  the  reader  to  his  original  paper, 
which  will  be  found  in  the  Zeitschrift  jilr  klinische  Medizin,  Berlin, 
1902. 


CHAPTEE    XXX. 

HEART   DISEASE  FROM  DIPHTHERIA  AND  OTHER  INFECTIONS- 
DISEASES  OF  THE  ARTERIES. 

HEART  DISEASE  RESULTING  FROM  DIPHTHERIA. 

The  form  of  licart  disease  whicli  results  from  the  diphtheritic  infec- 
tion (HfVers  remarkably  from  rheumatic  heart  disease. 

We  are  dealinji;  in  both  classes  of  cases  with  the  poisons  of  an  infective 
agent;  in  diphtheria,  however,  as  a  rule,  the  bacilli  do  not  gain  a  foot- 
hold in  the  cardiac  tissues,  but,  localized  to  the  area  of  the  throat,  they 
produce  poisons  which  circulate  in  the  blood. 

There  is  an  atmosphere  of  tragedy  surrounding  this  condition,  for 
there  is  brought  to  our  minds  the  recollection  of  sudden  and  unexpected 
deaths  occurring  at  a  time  when  ap])arently  the  acute  manifestations 
of  the  disease  are  over.  Yet  it  is  my  firm  belief  that  the  more  carefully 
these  cases  are  observed  and  treated,  the  less  fre(juently  will  these 
calamities  occur,  for  there  is  usually  some  warning  that  the  heart  is 
damaged  before  the  sudden  collapse  occurs.  In  becoming  acquainted 
with  the  experience  of  others,  I  have  been  surprised  with  the  differences 
that  exist  in  the  interpretation  of  slight  disturbances  of  the  heart  in 
diphtheria,  but  I  agree  with  those  who  attach  great  importance  to  them, 
however  slight  and  seemingly  trivial  they  may  be.  Treatment  may 
become  overcautious,  but  it  is  wise  to  run  no  risks  in  the  heart  disease 
of  di])htheria. 

Pathology. — I)ij)htheria,  when  it  damages  the  heart,  almost  invariably 
does  so  through  its  action  on  the  myocardium;  it  is  exceptional  to  find 
endocarditis  or  pericarditis,  and  should  either  of  these  conditions  be 
present  it  becomes  probable  that  there  is  a  mixed  infection. 

It  matters  Imt  little  from  the  point  of  view  of  practice  whether  the 
damage  commences  in  the  nerve  endings  or  in  the  muscle  fil)res,  but  it 
is  important  to  determine  whether  the  poisons  attack  the  vagal  centres 
in  the  medulla,  and  thus  aflFect  the  heart  indirectly  by  lesions  at  a 
distance  from  it.  If  these  centres  are  raj)idly  destroyed,  then  a  suddenly 
fatal  issue  may  occur  with  very  slight  warning. 

In  some  fatal  eases  wnth  paralysis  of  the  limbs,  changes  have  been 
demonstrated  in  the  anterior  cornual  cells  of  the  spinal  cord.  Batten 
is  of  opinion  that  the  dominant  nervous  lesion  is  a  parenchymatous 
degeneration  of  the  mvelin  sheath  of  the  nerves,  while  Bolton  found 
degenerative  changes  in  the  vagal  nucleus  in  the  medulla,  in  a  series  of 
cases  reported  in  the  Edinburgh  Medical  Journal,  April,  1902. 

It  also  seems  very  probable  that  there  is  direct  toxic  action  upon  the 
cardiac  muscle  fibres. 
(740) 


HEART  DISEASE  FROM  INFECTIOUS  DISEASES 


741 


In  some  cases  there  are  very  definite  changes  in  the  cardiac  muscle; 
changes  of  such  a  nature  that  some  considerable  period  of  time  must 
have  been  occupied  in  their  production.  Then  again  there  are  many,  not 
fatal,  but  which  resemble  these  in  their  clinical  features,  and  so  support 
the  view  that  the  cardiac  wall  is  often  the  seat  of  the  damage.  If  a 
microscopic  examination  is  made  the  muscle  is  in  some  cases  seen  to 
be  profoundly  altered.  Thus,  some  fibres  are  completely  destroyed,  and 
in  others  the  nuclei  are  swollen  or  shrunken  and  show  hyperchromatosis ; 
the  striation  of  the  fibres  is  lost  more  or  less  completely,  and  their  shape 
is  irregular;  extensive  fatty  changes  sometimes  occur  in  scattered  areas 
throughout  the  heart,  as  shown  in  the  accompanying  figure  (Fig.  156). 


Fig. 156 


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Myotardial  disease  in  diplittieritic  paralysis:  .1,  fatty  degeneration  of  a  muscle  fibre.  ^,  the 
same  in  cross-section.  C,  degenerating  muscle  fibre.  D,  muscle  fibre  destroyed.  E,  connective- 
tissue  cell. 


The  interstitial  tissues  show  little  change,  though  there  may  be  an 
increase  of  cellular  elements,  and  minute  hemorrhages  in  the  neighbor- 
hood of  the  small  bloodvessels. 

Symptomatology. — I  divide  these  cases  into  two  chief  groups,  but 
cannot  draw  any  hard-and-fast  line  between  them. 

The  first,  a  small  one,  contains  those  dangerous  forms  of  paralysis 
in  which  the  disease  is  widespread  and  implicates,  among  other  structures, 
the  respiratory  muscles.  In  these  the  condition  of  the  heart  is  but  one 
element  in  the  danger,  and  sometimes  not  the  most  prominent. 

Such  cases  as  these  are  most  serious,  and  many  of  them  die.     It  is 


742  DISEASES  OF    THE   HEART   AXD   BLOODVESSELS 

for  this  reason  very  necessary  to  study  the  symptoms  that  precede  the 
final  stages,  and  tlie  more  so'because  the  cU})"htheria  itself  may  be  over- 
looked. Sometimes  for  example  there  is  only  the  history  of  a  sore 
throat,  and  then  some  four  weeks  afterward  the  child  is  noticed  to  squint, 
liquids  regurgitate,  the  voice  becomes  nasal,  and  there  is  ataxy.  Vomit- 
ing may  follow,  or  there  may  be  difficulty  in  swallowing.  A  still  more 
alarming  symptom  is  a  curious,  ineffectual  cough,  which  always  means 
that  the  diaphragm  is  weak.  Examination  shows  that  the  epigastrium 
does  not  move  forward  in  inspiration,  or  that  the  diaphragm  is  com- 
pletely paralyzed  and  the  epigastrium  is  drawn  in  with  inspiration.  The 
pulse  is  quickened,  of  low  tension,  and  j>(>rhai)s  irregular.  The  cardiac 
impulse  is  ill-defined,  and  there  is  slight  dilatation  with,  it  may  l)e,  a 
systolic  apical  murmur.  Death  in  such  a  condition  is  frequently  very 
rapid,  and  at  the  best  there  must  be  the  greatest  anxiety  until  the  paralysis 
disappears.  The  causes  of  death  are,  usually,  engorgement  of  the 
lungs  from  the  respiratory  paralysis  and  arrest  of  the  enfeebled  heart, 
or  sudden  paralysis  of  the  heart  itself.  But  not  all  die;  some  recover 
even  when  at  death's  door,  and  it  is  the  condition  of  the  heart  which 
is  of  such  vital  importance  that  leads  me  to  describe  the  condition  here, 
rather  than  leave  it  entirely  to  the  article  on  Diphtheria. 

The  second  group  is  a  larger  one  and  includes  those  cases  in  which 
the  cardiac  weakness  is  the  prominent  symptom,  and  perhaps  the  only 
one.  The  evidences  show  themselves  usually  within  the  first  four  weeks, 
and  even  within  the  first  week  after  the  infection. 

If  the  child  is  in  bed,  and  that  is  the  rule  when  the  original  illness 
has  not  been  overlooked,  the  general  condition  undergoes  no  striking 
alteration,  though  pallor  and  muscular  feebleness  are  apparent  in  the 
more  severe  cases. 

It  is  the  pulse  and  heart  that  need  can^ful  physical  examination. 

The  pulse  is  altered;  it  may  be  unduly  rapid  or  slow  or  may  be 
irregular;  the  tension  is  low.  The  changes  in  the  heart  are  unobtrusive; 
the  impulse  is  feeble,  perhaps  irreguhir;  the  area,  on  careful  deep 
percussion,  is  slightly  increased,  especially  to  the  left;  the  first  sound 
at  the  apex  is  short,  and  there  may  be  a  soft  systolic  murmur,  usually 
heard  most  clearly  within  the  nipple  line;  the  pulmonary  second  sound 
is  accentuated,  and  sometimes  a  basal  systolic  murmur  is  audible. 
Yet  it  is  very  often  indeed  that  no  bruit  at  all  is  heard.  There  is  no 
edema,  no  pain,  no  startling  dyspnea.  If  the  child  is  running  about, 
fainting  attacks  occur,  and  then  it  is  fortunate  if  paralysis  of  the  limbs 
supervenes,  and  prevents — what  may  be  a  fatal  error — the  advice  that 
the  child  should  be  sent  to  the  seaside  to  recover  from  the  debility. 

The  urine  in  all  cases  should  be  tested  for  the  presence  of  albumin. 
^Yhen  the  fatal  result  is  approaching  the  face  is  pale,  the  respiration 
sighing,  and  the  extremities  are  cold,  but,  as  a  rule,  there  is  no  delirium. 

Dr.  Villy,  in  an  excellent  paper  (Medical  Chronicle,  September,  1S99), 
emphasizes  the  importance  of  vomiting  in  these  cases.  This  vomiting 
is  associated  with  organic  changes  in  the  mucous  membrane  of  the 
stomach,  and  may  precede  the  cardiac  weakness. 


HEART  DISEASE  FROM   INFECTIOUS  DISEASES  743 

The  vast  majority  of  cases  in  this  group  recover,  with  careful  treat- 
ment, but  some  of  them  are  very  slow  in  so  doing,  and  tachycardia 
irregularity,  and  impairment  of  the  force  of  the  heart  sometimes  lasts 
for  many  months,  or  even  for  some  years. 

Diagnosis. — The  diagnosis  of  heart  disease  in  diphtheria  requires 
care,  and  the  absence  of  any  striking  murmurs  has  led  to  many  mistakes. 
The  danger  of  an  oversight  is  much  increased  if  the  history  of  diphtheria 
is  not  clear. 

The  method  of  making  outlines,  as  already  recommended  (p.  684),  is 
very  useful  in  this  condition  also,  as  a  check  to  hasty  examination. 

Any  cause  of  dilatation  of  the  heart  will  have  to  be  reckoned  with 
in  forming  a  judgment,  but  influenza,  and  some  rheumatic  cases  which 
damage  the  myocardium  disproportionately,  are  those  which  are  the 
most  difficult  to  exclude. 

The  other  evidences  of  diphtheritic  paralysis  must  be  sought  for, 
and  cultures  taken  from  the  fauces  for  the  discovery  of  the  Klebs- 
LoeflBer  bacillus. 

Fig.  157 


Reins  for  controlling  the  movements  of  a  child  suffering  from  diphtheritic  heart  disease  :  A.  C. 
arm  straps;  B,  chest  strap;  D,  E,  F,  strap  slipped  through  A  and  C,  passing  beneath  the  child  and 
buckled  to  the  frame  of  the  bed;  6,  position  of  strap,  B,  E,  F. 

Prognosis. — This  is  always  grave  in  the  severe  cases,  but  in  those  in 
which  there  is  only  slight  dilatation  or  irregularity  it  is  good.  If  the 
heart  is  damaged  in  the  first  ten  days  the  outlook  is  more  serious. 

Dangerous  symptoms  are  the  occurrence  of  pharyngeal  and  respir- 
atory paralyses,  severe  vomiting,  great  pallor,  restlessness,  and  syncopal 
attacks. 

Turning  to  the  heart  itself,  a  rapid,  ill-sustained  pulse  or  a  very  slow 
pulse  is  serious,  and  when  the  two  sounds  of  the  heart  are  closely  approx- 
imated this  must  be  looked  upon  as  a  sign  of  the  greatest  danger. 

The  extent  of  dilatation  is  not  a  reliable  index,  for  the  worst  cases 
may  show  but  little  enlargement  of  the  deep  cardiac  dulness. 

Treatment.  General  Management. — In  the  first  class  of  cases  treat- 
ment is  heavily  handicapped  by  the  lack  of  any  drug  which  has  a  con- 
trolling power' over  the  spread  of  the  paralysis,  and  yet  should  it  spread 
even  a  little  farther  the  child  must  die.     The  Uves  that  are  saved  are 


744  DISEASIuS  OF    rilK   HEART   AM)    BLOODVESSELS 

triumphs  of  a  skilled  nianaorement  which  has  kept  the  strength  iiiaiii- 
tained  until  the  natural  recovery  commences.  Specially  trained  nurses 
are  invaluahle,  for  they  realize  the  danjjjer  of  sudden  movements,  such 
as  the  assumption  of  the  sitting  or  erect  positions,  and  they  understand 
how  to  feed  the  child  and  how  to  attend  to  its  wants  with  the  least 
possible  disturbance.  Useful  hmus  for  controlling  the  child  are  those 
shown  in  Fig.   157. 

Solid  food  can  often  be  given  with  great  Ix-nefit  in  these  cases  and, 
if  the  nurse  is  skilful,  can  be  persisted  with  even  when  the  paralysis 
would  seem  to  counterindicate  it.  Failing  this,  nourishing  Huids  should 
be  given.  In  some  cases  these  are  best  thickened  with  a  little  arrowroot; 
in  others,  even  though  swallowing  is  difficult,  the  liquids  are  taken 
better  unthickened.  Milk,  beef-tea,  and  th(>  yolk  of  a  raw  egg  may  be  used, 
and,  if  necessary,  the  milk  must  be  peptonized.  (Ireat  care  should  be 
taken  not  to  hurry  the  child  and  thus  cause  it  to  choke  and  aid  the 
supervention  of  bronchopneumonia  by  the  aspiration  of  fluid  into  the 
air  passages. 

If  vomiting  is  severe,  nutrient  peptonized  enemata  of  milk  and  beef- 
tea  with  some  brandy  or  whiskey  are  needed,  but  the  outlook  is  very 
gloomy  when  these  are  called  upon.  Resort  may  also  be  had  to  saline 
infusions  under  the  skin  as  follows: 

Ijk— Normal  saline  solution. 

Tlie  white  of  one  egg. 

Glucose  to  make  a  5  per  cent,  solution. 
To  make  2  ounces  (60  c.c). 

Nasal  feeding,  which  in  children  is  usually  more  successful  than  the 
passage  of  the  tube  by  the  mouth,  is  most  valuable  if  done  skilfully, 
but  let  me  warn  against  one  danger.  It  may  be  that  the  patient  has 
taken  but  little  food  l)y  the  mouth,  for  some  has  been  regurgitated  and 
some  rejected,  and  now,  when  the  tube  has  heea  passed  into  the  stomach, 
an  effort  is  made — well-intentioned  enough — to  cover  the  deficit  by  a 
hastily  given,  large,  and  concentrated  meal.  The  result  may  be  most 
disastrous;  the  feeble  muscular  wall  of  the  stomach  gives  way,  the 
stomach  dilates  and  presses  upon  the  already  embarrassed  heart,  causing 
sudden  death,  or,  if  not  that,  grav(>ly  imj)erilling  the  recovery.  Stimu- 
lants in  the  form  of  l)randy  I  give  freely,  though  there  is  no  consensus 
of  opinion  upon  this  point;  it  should  be  given  to  a  child  of  five  to  ten 
years  as  a  medicine  in  a  little  water,  in  doses  of  8  c.c.  (2  dr.)  or  more 
every  four  hours,  night  and  day. 

It  is  a  mistake  to  treat  these  cases  with  great  energy;  they  should 
be  examined  as  little  as  possible,  and  their  food  and  medicines  arranged 
so  as  to  prevent  continued  disturbance.  The  bowels  are  better  regu- 
lated by  carefully  given  enemata  than  by  purgatives.  When  the  dia- 
phragm is  paralyzed,  it  is  not  advisable  to  let  the  child  lie  persistently 
on  the  back,  and  he  should  be  turned  gently  on  to  the  side  from  time 
to  time.  Some  raise  the  foot  of  the  bed,  thus  hoping  to  aid  the  drainage 
of  the  edematous  fluid  from  the  lungs.  It  is  essential  to  avoid  exposure 
and  chilling  of  the  surface,  for  an  added  bronchitis  will  be  fatal. 


HEART  DISEASE  FROM   INFECTIOUS  DISEASES  745 

Oxygen  is  serviceable  when  the  breathing  is  embarrassed  and  the  color 
bad,  and  should  then  be  used  continuously. 

From  such  remedies  as  electricity  or  leeches  to  lessen  the  congestion 
I  have  seen  no  advantage. 

Medicinal  Treatment. — The  drug  usually  relied  upon  is  strychnine. 
The  greatest  effect  is  obtained  by  hypodermic  injection,  but  it  is  well 
to  begin  first  with  doses  by  the  mouth.  Dr.  D.  B.  Lees  strongly  advo- 
cates its  combination  with  atropine  in  full  doses  in  such  a  prescription 
as  the  following  one: 

56:— Liq.  atrop.  sulphatis  (B.  P.) 0.06  c.c.  (1  minim.) 

Liq.  strj-chuiffi  sulphat.  (B.  P.J COG  c.c.  (1  minim.) 

Syrup,  aurantii  cort 0.60  c.c.  (10  minims. ) 

Aq.  chloroform q.  p.  ad  8.00  c.c.  (2  dracbms.)— M. 

Sig.— Two  drachms  (8  c.c.)  every  four  hours. 

The  atropine  is  pushed  until  dryness  of  the  mouth,  dilated  pupils, 
and  a  dry  skin  are  noted. 

Improvement  shows  itself  in  an  evident  way  by  the  return  of  the 
movement  of  the  diaphragm,  increase  in  the  volume  and  strength  of 
the  pulse,  decrease  in  the  area  of  cardiac  dulness,  and  a  greater  distinct- 
ness in  the  character  of  the  heart  sounds. 

Unfortunately  a  relapse  may  occur,  but  if  not  the  improvement  is 
slow  and  steady.  No  relaxation  of  precautions  must  be  permitted 
for  a  moment  until  all  traces  of  the  respiratory  and  cardiac  paralyses 
have  disappeared,  and  when  the  emergency  is  past  the  treatment  will 
be  such  as  will  be  described  for  the  second  and  less  fatal  group  of 
cases. 

However  mild  a  case  of  diphtheria  may  be,  it  is  advisable  to  keep 
the  child  in  bed  for  three  weeks  after  the  disappearance  of  the  mem- 
brane. Then  each  step  forward  is  taken  cautiously,  and  a  month 
will  have  been  passed  before  the  heart  and  pulse  are  allowed  to  escape 
careful  observation.  It  is  the  last  week  that  needs  special  watchfulness. 
The  bed-rest,  sitting  up,  lying  on  the  couch,  and  the  first  exercise, 
all  these  are  events  in  the  convalescence  which  need  testing,  and  irregu- 
larity of  the  heart's  action  or  slight  dilatation  should  delay  the  advance. 
The  knee-jerks  must  be  tried  while  the  child  is  in  bed,  for  by  their  dis- 
appearance they  sometimes  give  an  early  warning  of  paralysis. 

A  useful  routine  prescription  is  the  following  mixture  of  iron  and 
nux  vomica,  and  quinine  in  small  doses  is  also  a  valuable  tonic: 

9;— Liq.  ferri  i)erchloridi  (B.  P.) 0.3  c.c.  (5  minims.) 

Tinct.  nucis  vomicffi 0.2  c.c.  (3  minims.) 

Syrup,  aurantii  cort 1.3  c.c.  (20  minims.) 

Aq.  chloroformi q.  s.  ad  8.0  c.c.  (2  drachms. )—M. 

Sig.— Two  drachms  (8  c.c.)  three  times  a  day  for  a  child  of  four  years. 

:^—Quinin.  sulphat 0.03  gm.  0^  grain.) 

Acid,  sulphurici  aromat.  dil 0.13  c.c.  (2  minims.) 

Glycerini 1.30  c.c.  (20  minims.) 

Aq.  chloroformi q.  s.  ad  8.00  c.c.  (2  drachms.)— M. 

Sig.— Two  teaspoonfuls  (8  c.c.)  three  times  a  day. 

It  is  not  advisable  in  these  cases  to  use  powerful  drugs  such  as  digitalis 
and  strophanthus,  which  alter  rhythm  of  the  heart;  nor  should  Tadvise 


746  DISEASES  OF   THE   HEART   AXD   BLOODVESSELS 

the  coininon  practice  of  stimulatini;  the  heart  w itli  liypodermie  injections 
of  strvchnine.  None  of  these  powerful  (h-M<;s  lias  a  directly  curative 
effect  on  the  cardiac  muscle.  Strychnine,  hy  getting  the  full  use  out  of 
the  healthy  fibres,  is  most  valuable  at  a  time  of  urgency,  but  the  tendency 
is  to  abuse  it. 

As  a  rule  the  slight  disturbances  after  di}>htheria  get  tpiite  well,  and 
when  this  is  so  a  change  to  seaside  or  country  will  correct  the  anemia 
and  t'eneral  debility.  But  sometimes  the  heart  does  not  recover  com- 
pletely for  many  months.  Tachycardia,  dilatation,  and  breathlessness 
are  complained  al)out,  and  the  parents  remark  upon  the  great  change 
in  the  general  health  of  the  child  since  the  illness.  Time  and  caution 
are  the  two  first  necessaries.  The  bowels  must  be  regulated  and  all 
violent  exercises  prohibited.  Steady  exertion,  such  as  a  quiet  walk 
every  day,  will  often  do  good,  unless  it  shoultl  be  that  this  causes  pal- 
pitation and  irregularity.  Sehoolwork,  heated  rooms,  and  children's 
parties  should  be  exchanged  for  nature's  lessons  in  the  country,  pure 
air,  and  an  hour's  rest  after  the  midday  meal.  A  good  wholesome 
diet  is  most  important. 

So  far  as  I  am  aware  no  drug  has  a  curative  effect  upon  these  weak- 
ened hearts,  but  general  tonics  are  very  serviceable. 


HEART   DISEASE  RESULTING   FROM  SUPPURATIVE   INFECTIONS. 

Suppurative  Pericarditis.  Etiology. — This  is,  perhaps,  one  of  the 
most  difficult  of  the  diseases  of  childhood  to  diagnosticate  or  to  treat  with 
success,  and  though  not  common  can  hardly  be  called  rare.  There  is 
no  tloubt  that  all  those  microbic  infections  which  produce  suppuration 
can  cause  suppurative  pericarditis,  but  ex])erience  has  shown  that  about 
80  per  cent,  of  the  total  number  are  associated  with  pulmonary  diseases. 
This  same  percentage  represents  cases  of  suppurative  pericarditis  occur- 
ring in  children  under  four  years  of  age.  "With  at  least  GO  per  cent,  an 
empyema  is  associated,  while  in  other  cases  abscess  and  gangrene  of 
the  lung,  mediastinal  abscess,  suppurating  bronchial  lymph  nodes, 
tuberculosis,  and  pneumonia  have  been  recorded.  Osteomyelitis  and 
general  pyemia  resulting  from  suppurating  wounds  are  the  antecedents 
in  a  small  percentage  of  the  cases. 

Measles,  influenza,  and  other  infective  diseases  predispose  to  suppu- 
rative pericarditis,  and  in  addition  to  respiratory  diseases — meningitis  and 
peritonitis  have  been  frequently  noted  as  occurring  simultaneously  with 
the  pericarditis.  The  cardiac  valves  are  rarely  damaged — a  fact  strongly 
in  favor  of  the  specific  nature  of  rheumatic  fever — and  it  is  quite  excep- 
tional to  fin<l  su])purative  pericarditis  as  the  primary  lesion. 

Pathology. — After  death  the  pericarditis  may  l)e  found  either  in  the 
earliest  stages  or  well  aflvanced.  It  may  recpiire  careful  observation 
to  detect  a  few  flakes  of  exudation,  or  there  may  be  great  distention  of 
the  pericardium,  with  as  much  as  six  or  seven  ounces  of  liquid  pus 
in  the  sac.     The  parietal  pericardium  is  sometimes  greatly  thickened, 


HEART  DISEASE  FROM  INFECTIOUS  DISEASES 


747 


but  the  heart  is  often  not  dilated  at  all,  and,  except  that  the  muscle  sub- 
stance is  somewhat  pale,  is  otherwise  normal. 

The  exudation  is  sometimes  in  the  form  of  creamy  pus  and  some- 
times there  are  fibrinous  strands,  but,  as  a  rule,  there  is  rapid  solution 
of  the  fibrinous  elements  and  no  adhesion  (Fig.  158). 

In  very  exceptional  cases  an  abscess  in  connection  with  the  air  passages 
may  open  into  and  infect  the  pericardium,  thus  giving  rise  to  pneumo- 
pyopericardium.  Since  bacteriological  investigations  have  been  made, 
the  streptococcus  lanceolatus  is   the  bacterium  that  has   been  found 


Fig.  158 


Suppurative  pericarditis.    The  pericardium  is  opened;  thie  sac  was  greatly  distended  witli  a 

purulent  fluid. 


most  often  in  the  pus,  for  it  is  the  micro-organism  especially  responsible 
for  the  pulmonary  disease.  In  cases  of  osteomyelitis  the  staphylococcus 
aureus  has  been  isolated,  and  in  some  instances  the  streptococcus 
pyogenes. 

In  the  days  when  empyemata  were  not  treated  surgically,  one  of  the 
common  terminations  was  suppurative  pericarditis.  This  points  to  the 
infection  of  the  pericardium  being,  in  some  instances,  secondary  to  the 
pleural  disease.  There  are,  however,  other  cases  in  which  it  seems 
equally  clear  that  the  pericarditis  is  a  part  of  a  general  infection  of  the 
serous  membranes. 


748  DISEASES  OF    THE   HEART   A\D   BLOODVESSELS 

Symptomatology. — The  following  cases  well  exemplify  the  usual  course 
of  the  illness  and  (fives  a  Ix'tter  idea  of  the-  <feneral  course  of  the  disease 
than  a  mere  repetition  of  probable  symptoms  would  do: 

Case  I. — J.  G.,  aged  nine  months,  came  under  observation  for  cough, 
wasting,  vomiting  and  diarrhea.  The  illness  had  been  gradually  devel- 
oj)ing  for  six  weeks.  The  previous  history  and  family  history  were  un- 
imj)ortant. 

There  was  dulness  over  the  upper  lobe  of  the  left  lung,  also  in  the 
upper  part  of  the  left  axilla  and  posteriorly  down  to  the  level  of  the 
inferior  angle  of  the  scapula.  Over  this  dull  area  the  breath  sounds 
were  diminished  and  the  breathing  bronchial.  At  the  right  base  pos- 
teriorly there  were  nmnerous  rales.  The  limits  of  the  deep  cardiac 
dulness  were  :  Above,  the  second  rib;  to  the  left,  the  vertical  nipple  line; 
to  the  right,  one-half  inch  external  to  the  right  sternal  margin;  the 
cardiac  sounds  were  normal.  The  temperature  was  102°  F.,  pulse  IGO, 
respiration  38.  The  probable  diagnosis  was  tuberculosis.  The  tem- 
perature fell,  but  still  the  child  lost  ground;  now  two  sharp  crepitations 
were  detected  over  the  dull  area  and  impairment  of  resonance  over  the 
right  lung  posteriorly,  reaching  down  to  the  fifth  rib.  Death  occurred 
on  the  tenth  day.  Necropsy  showed  empyema  between  the  left  lung 
and  pericardium,  and  also  over  the  upper  part  of  the  right  lung. 
There  were  also  bronchopneumonia  and  suppurative  pericarditis  with 
an  ounce  of  pus  in  the  pericardial  sac.  By  bacteriological  culture  the 
streptococcus  lanceolatus  was  found. 

Case  II. — 'SI.  P.,  aged  two  years,  came  under  observation  for  cough, 
anorexia,  and  drowsiness.  The  child  was  thin,  pale  and  rickety.  The 
prominent  symptoms  were  severe  dyspnea  and  feeble  pulse,  the  rate  of 
which  was  IGS  to  the  minute.  The  cardiac  dulness  was  limited:  Above, 
by  the  second  intercostal  space;  on  the  left  it  reached  one-half  inch 
external  to  the  vertical  nipple  line;  to  the  right  it  reached  just  below 
the  right  margin  of  the  sternum.  The  heart  sounds  were  feeble.  The 
l)ulmonary  sounds  were  as  follows:  There  was  dulness  on  percussion 
and  loss  of  breath  at  the  right  base  posteriorly,  with  crepitations  at  the 
left  aj)ex.  The  left  lung  otherwise  appeared  normal.  Exploration  of 
the  right  pleura  discovered  pus,  which  was  dealt  with  in  the  usual  way. 
There  was,  however,  no  improvement.  The  temperature,  which  had 
been  irregular,  reaching  103°  F.,  continued  unaltered,  and  lividity  and 
syncopal  attacks  were  noted.  The  child  died  suddenly  nineteen  days 
after  admission.  Autopsy  showed  a  small  empyema  in  the  left  pleura, 
and  purulent  pericarditis. 

In  neither  of  these  cases  was  there  pericardial  friction. 

It  is  apparent  that  the  absence  of  pericardial  friction  and  the  presence 
of  pulmonary  disease  greatly  complicate  any  description  or  detection 
of  the  pericarditis.  When  the  condition  is  an  incident  in  a  weneral 
pyemic  infection  it  may  also  be  overlooked  entirely,  although,  in  excep- 
tional cases,  loud  pericardial  friction  has  established  the  diagnosis. 

Diagnosis.— The  diagnosis  is  most  difficult  because  pericardial  friction 
is  very  rarely  detected,  and  the  condition  is  just  sufficiently  rare  to 


HEART  DISEASE  FROM   INFECTIOUS  DISEASES  749 

make  the  experience  of  one  failure  fade  from  the  memory  before  the 
next  opportunity  is  presented;  nevertheless,  there  is  sometimes  such  a 
definite  effusion  and  such  evidence  of  a  distended  pericardium  that  the 
diagnosis  is  made  with  confidence,  as  in  this  case: 

F.,  aged  four  and  one-half  years,  was  admitted  to  St.  Mary's  Hospital, 
December  22d,  suffering  from  right  lobar  pneumonia.  On  admission  the 
impulse  of  the  heart  was  noted  to  be  below  and  internal  to  the  left  nipple, 
where  it  could  be  both  seen  and  felt.  There  was  persistent  dulness  at 
the  right  base,  and  on  December  31st  an  empyema  was  drained.  There 
was  no  improvement;  the  child  became  feeble,  cyanotic,  and  distressed. 
On  January  4th  the  cardiac  area  was  as  follows:  Upper  limit,  second 
left  costal  cartilage;  left  limit,  one  finger  breadth  external  to  the  left 
vertical  nipple  line;  right  limit,  just  internal  to  the  right  vertical  nipple 
line.  The  sounds  of  the  heart  were  so  faint  as  to  be  almost  inaudible, 
and  over  the  precordial  area  of  increasing  resistance  upon  percussion. 
Dr.  Pepper  opened  and  drained  the  pericardium  that  evening,  but  the 
child  sank  and  died  twelve  days  later.     This  is  an  exceptional  case. 

Far  more  often  the  attention  of  the  physician  is  centred  on  the  pul- 
monary disease,  and,  to  the  end,  it  is  supposed  that  a  loculated  empyema 
has  been  overlooked  or  that  there  is  a  relapsing  bronchopneumonia  or 
tuberculosis.  Finally,  the  development  of  suppurative  meningitis  may 
complete  the  confusion. 

This  much  seems  clear,  that  when  in  children  under  four  years  of  age 
an  empyema  or  bronchopneumonia  has  been  detected,  and  the  course 
of  the  disease,  in  spite  of  correct  treatment,  is  unsatisfactory,  or  if  pus 
is  liberated  from  the  pleura  and  the  temperature  still  remains  high,  and 
there  are  wasting  and  steady  loss  of  strength,  then  suppurative  peri- 
carditis is  a  probable  complication.  This  is  the  more  likely  if  the  illness 
has  occurred  during  an  outbreak  of  influenza,  or  after  some  infection 
such  as  measles.  When  the  possibility  of  the  danger  is  kept  in  view, 
there  are  other  symptoms,  more  or  less  equivocal,  which  may  lead  to 
the  diagnosis.  Great  rapidity  of  the  pulse  with  irregularity,  vomiting 
and  livid  pallor,  panting  respiration  and  orthopnea,  with  frequent 
fainting  attacks,  have  all  been  recorded.  When  there  is  progressive 
muffling  of  the  heart  sounds,  and,  simultaneously,  an  increase  in  the 
a.rea  of  cardiac  dulness,  that  evidence  is  exceedingly  valuable.  Yet  it 
is  unfortunate  that  even  this  evidence  is  difficult  to  obtain;  for  the 
pulmonary  affection  itself,  by  possibly  causing  consolidation  or  collapse, 
or  the  formation  of  fluid  in  the  region  of  the  pericardium,  complicates 
and  makes  difficult  the  study  of  the  cardiac  dulness.  An  impairment 
immediately  to  the  left  or  right  of  the  sternum,  if  disproportionate  to 
any  impairment  elsewhere,  is  highly  suggestive  of  fluid  in  the  pericardial 
sac;  nor  should  it  be  forgotten  that  the  dulness  on  the  left  side — due  in 
part  to  pulmonary  collapse — will  extend  in  this  condition  even  up  to 
the  left  clavicle.  Naturally,  pericardial  friction  is  always  listened  for, 
but  is  rarely  heard. 

In  a  large  pericardial  effusion  the  pulse  is  rapid,  the  wave  small,  ill- 
sustained,  and  sometimes  very  irregular.     There  may  be  some  bulging 


750  DISEASES  OF    THE   HEART   AXD    liLOODVESSELS 

of  the  precordial  urea.  The  impulse  is  either  absent  or  an  luuhilating 
movement  may  be  seen  in  the  tliird  or  fourth  space  on  the  left  side. 
On  palpation,  either  no  cardiac  impulse  at  all  is  felt  or  only  a  distant 
tap  is  detected. 

The  area  of  deep  cardiac  dulness  is  jjjreatly  increased  and  is  pear- 
shaped,  with  the  stalk  of  the  pear  in  the  position  of  the  large  blood- 
vessels. 

The  change  from  the  absolute  dulness  over  the  fluid  in  the  pericardial 
sac  to  the  ])ulinonary  resonance  is  a])ru])t  and  strikin<,'. 

The  sounds  of  the  heart  are  distant,  or  may  even  be  inaudible  and 
give  the  impression  that  the  heart  has  been  lost. 

In  young  children,  collapse  of  the  upper  lobe  of  the  left  lung  may 
cause  the  dulness  to  rise  as  high  as  the  left  clavicle. 

Prognosis. — The  prognosis  is  certainly  very  grave,  fn  the  cases  in  which 
it  is  part  of  a  general  pyemia,  death  is  almost  inevitable,  and,  moreover, 
until  the  diagnosis  can  be  more  readily  made  the  vast  majority  of  all 
cases  nnist  die.  The  only  hope,  at  present,  lies  in  surgical  intervention, 
and  it  occasionally  saves  the  life  of  the  patient. 

Treatment. — Palliative  mea,sures,  so  far  as  the  saving  of  life  is  con- 
cerned, are  useless,  but  they  promote  euthanasia.  It  is  from  some 
active  serum  that  we  must  look  for  help,  but  at  present  there  is  no 
such  remedy. 

The  (Irainac/c  of  the  pericardium  is,  therefore,  at  this  time  our  only 
resource,  and  the  recent  advances  in  cardiac  surgery  nnist  encourage 
us  to  explore  the  pericardium  with  less  dread  than  hitherto. 

The  surgical  measures  that  can  be  adopted  are  two,  viz.,  paracentesis 
of  the  pericardium  and  incision  and  drainage.  The  first  is  only  of 
value  in  those  cases  in  which,  owing  to  the  cpuintity  of  fluid  in  the  sac, 
there  is  embarrassment  of  the  heart,  yet  the  condition  of  the  patient  is 
too  serious  to  permit  an  anesthetic.  Then  by  paracentesis  the  pressure 
can  be  relieved,  and  an  opportunity  is  given  for  the  circulation  to 
recover.  With  the  improvement  in  the  patient's  condition  the  more 
radical  operation  can  be  undertaken. 

In  operations  upon  the  pericardium  it  should  be  remembered  that 
the  level  at  which  the  left  pleura  leaves  the  middle  line,  as  given  by 
Luschka — at  the  fourth  costal  cartilage — is  only  correct  in  a  small  pro- 
portion of  cases.  As  a  rule,  the  left  {)leura  does  not  leave  the  middle 
line  until  the  level  of  the  fifth  or  sixth  costal  cartilage  is  reached. 

Paracentesis,  as  Roberts  has  pointed  out,  is  most  safely  performed 
by  the  introduction  of  the  needle  in  the  left  costoxiphoid  angle;  the 
needle  should  graze  the  lower  end  of  the  body  of  the  sternum  and  pass 
up  and  in,  behind  the  sternum,  to  the  cavity  of  tiie  ])ericardium. 

Another  site  often  chosen  is  the  fifth  left  interspace  close  to  the 
sternum;  the  needle  should  pass  inward,  but  there  is  some  danger  of 
piercing  the  pleura. 


HEART  DISEASE  FROM   INFECTIOUS  DISEASES 


751 


MALIGNANT  ENDOCARDITIS  THE  RESULT  OF  PYOGENIC 
INFECTIONS. 

Etiology. — The  pyogenic  micro-organisms  are  also  a  cause  of  malig- 
nant endocarditis.  Yet  it  is  remarkable,  when  the  frequency  of  suppu- 
rative lesions  in  childhood  is  remembered,  how  very  rarely  this  condition 
arises. 

Osteomyelitis,  pneumonia,  an  abscess  in  the  lung  or  an  abscess 
resulting  from  injury  may  be  the  starting  point  of  the  infection,  but  the 
most  important  group  is  that  which  occasionally  follows  suppuration  in 
the  middle  ear.  This  group  is  one  of  special  interest  because  the  symp- 
toms that  arise  may  very  closely  resemble  those  of  acute  rheumatism. 

Fia.  159 


Septic  endocarditis.  (Adams,  Jacobi's  Festschrift. 


Symptomatology. — The  symptoms  of  the  malignant  endocarditis 
which  results  from  pyogenic  infections  are  usually  more  acute  and 
severe  than  those  which  follow  the  rheumatic  infection,  but  the  general 
resemblance  is  a  close  one.     (See  Chap.  XXVIII.) 

They  may  be  grouped  under  two  headings,  viz.,  those  which  are  the 
result  of  the  toxemia:  irregular  fever,  sweating,  rigors,  drowsiness  or 
delirium,  diarrhea,  progressive  anemia,  emaciation  and  purpura;  and 
those  which  result  from  the  valvular  disease:  cardiac  excitement,  pre- 
cordial pain,  valvular  bruits,  and  dilatation  (Fig.  159).  Fragments  of 
the  vegetations  detached  from  the  valves  will  produce  infarctions,  which 


752  DISEASES  OF    TIIK   HEART   AM)    liLOODV ESSELS 

later  iiiav  <,mvc  rise  to  ahscesses  in  the  kidneys,  spleen,  lungs,  brain,  or 
even  the  cardiac  wall  itself.  An  aneurvsin  of  the  heart  may  result  from 
severe  invocarditis  with  suppuration.  It  is  sonietiuies  possible  to  detect 
this  aneurysm  by  a  local  bul<i;in<^  of  the  precordium,  or  by  the  develop- 
ment of  a  bruit,  the  maximum  intensity  of  which  is  in  some  unusual 
situation,  or  by  a  curious  whizzing  sensation  imparted  to  the  hand 
placed   over  the  heart. 

Prognosis  and  Treatment. — These  cases  of  malignant  endocarditis 
which  follow  pyogenic  infections  are  most  fatal,  and  although  prepa- 
rations of  c|uinine  or  serum  injections  arc  freely  used,  no  method  of 
treatment  has  met  with  continued  success. 


HEART  DISEASE  RESULTING  FROM  SCARLET  FEVER. 

Heart  disease  sometimes  follows  an  attack  of  scarlet  fever,  as  do  also 
arthritis  and  chorea.  The  result  nuiy  be  a  severe  and  even  fatal  peri- 
carditis or  chronic  valvular  disease,  or,  in  some  rare  cases,  ulcerative 
endocarditis.  The  clinical  course  of  these  cases  resembles  rheumatic 
heart  disease  so  closely  that  they  will  need  no  detailed  description. 

The  following  summaries  give  an  idea  of  cases  which  are  rapidly 
fatal : 

Case  I. — A  girl,  aged  four  years,  twelve  days  after  the  appearance 
of  the  rash,  developed  pneumonia  and  pericarditis,  which  proved  fatal 
in  a' week. 

Case  II. — A  boy,  aged  six  years,  six  weeks  after  the  rash  developed 
pleurisy  and  pericarditis  and  died  in  a  fortnight. 

C.\SE  III. — A  boy,  aged  seven  years,  eighteen  days  after  the  rash 
developed  pleurisy  and  pericarditis,  which  proved  fatal  in  twelve  days. 

Nephritis  may  complicate  the  pericarditis,  while  in  other  fatal  cases 
the  immediate  cause  of  death  has  been  nejihritis,  but  early  endocarditis 
of  the  aortic  or  mitral  valve  has  been  discovered  at  the  necropsy. 

Symptomatology. — The  clironic  valvular  disease  following  scarlet  fever 
seems  to  me  to  be  accompanied  by  more  hypertrophy  of  the  heart  and 
more  definite  symptoms  of  cardiac  distress  than  that  following  rheu- 
matism. Certainly,  in  other  respects,  this  form  of  heart  disease  is 
exceedingly  like  the  rheumatic  form,  and  there  is  also  with  it  a  liability 
to  attacks  of  acute  arthritis. 

Diagnosis. — This  is  usually  plain,  for  either  immediately  after  an 
attack  of  the  scarlet  fever  there  has  been  a  severe  cardiac  inflammation, 
or  closely  following  the  illness  there  have  been  complaints  of  precordial 
pain  and  breathlessness.  Again,  chorea  and  arthritis  may  have  occurred 
during  a  delay  in  the  convalescence  from  scarlet  fever,  and  these  will 
suggest  the  origin  of  the  heart  disease. 


HEART  DISEASE  FROM   IXFECTIOUS  DISEASES 


753 


HEART  DISEASE  RESULTING  FROM  TUBERCULOSIS. 

In  tuberculosis  of  the  heart,  as  in  rheumatic  disease,  the  valves  and 
pericardium  are  liable  to  damage.  It  is  not  at  all  common  in  England, 
at  least  as  a  cause  of  heart  disease,  although  in  the  postmortem  records 
of  the  Hospital  for  Sick  Children,  Great  Ormond  Street,  there  are  a 
considerable  number  of  cases  in  which  tubercles  have  been  observed 
in  the  heart  wall;  in  the  great  majoritv  of  these  there  were  no  recogniz- 
able signs  of  heart  disease  during  life,  and  the  occurrence  was  only  an 
incident  in  a  tuberculosis  which  was  more  or  less  generalized. 

The  following  are  the  chief  types:  1.  Chronic  endocarditis.  2.  Peri- 
carditis with  or  without  extensive  effusion.  3.  ^Multiple  serositis.  4. 
Malignant  endocarditis  in  a  child  sufferino-  from  tuberculosis. 


Tuberculous  endocarditis.    The  left  ventricle  is  opened  and  shows  a  large  vegetation  on  the  mitral 
valve.    (From  the  Museum  of  the  Children's  Hospital,  Great  Ormond  Street.) 

Chronic  Endocarditis. — In  this  group  occur  cases  in  which  the  valves 
only  are  attacked,  and  in  which  calcification  sometimes  converts  the 
valves  and  valve-rings  into  a  rigid  wall. 

There  is  no  history  of  rheumatism.  The  occurrence  of  tuberculosis  in 
other  viscera  and  the  dating  of  the  cardiac  disorder  from  an  outbreak  of 
tuberculous  infection  indicate  the  true  nature  of  the  infection  (Fig.  160). 

They  appear  clinically  as  cases  of  mitral  incompetence  or  stenosis,  or, 
as  in  one  case  which  came  under  my  notice,  of  a  mitral  and  tricuspid 
stenosis.  Their  course  may  be  verv  chronic,  but  there  is  always  the 
dano-er  of  death  occurring  from  some  tuberculous  affection,  and  menin- 
gitis  is  especially  to  be  feared. 

Tuberculous  Pericarditis. — Riesman  has  pointed  out  the  importance 
of  extension  of  tuberculous  disease  to  the  pericardium  from  caseating 
48 


754  DISKASI-JS  OF    THE   HEART   AM)    HLOODVESSELS 

Ivmph  nodes  in  tlu-  antorior  mediastinum.  Tlio  prricarditis  is  usually 
chronic  and  results  in  dense  adhesions,  hut  may  he  acute  with  great 
elVusion  needing  paracentesis.  Only  in  exceptional  cases  has  it  heen 
possihle  to  prove  experimentally  the  true  nature  of  the  infection.  The 
diagnosis  is  necessarily  difficult,  but  there  is  no  history  of  rheumatism, 
and  there  may  be  no  valvular  disease.  These  two  facts  alone,  in  a 
child  of  tuberculous  stock,  or,  still  more,  in  one  suffering  from  tubercle 
in  some  other  organs,  are  suspicious.  Pericardial  friction  may  be  iieard 
m  some  cases,  but  in  others  the  acute  stage  has  been  so  unobtrusive 
as  to  be  overlooked. 

Tuberculous  Multiple  Serositis.— This  third  group  is  not  sharply 
differentiated,  for  valvular  damage  may  occur  also.  The  predominant 
feature  is  the  occurrence  of  pericarditis  ivith  pleurisy  or  peritonitis  or 
w'ith  both.    The  following  case  is  a  good  example  of  the  type : 

A  delicate  boy,  aged  three  and  one-half  years,  was  said  to  have  had 
a  fit  in  Aj)ril  followerl  by  diarrhea  and  some  bronchitis.  In  May  he 
was  under  observation  for  feverishness  and  wasting.  There  was  no 
personal  or  family  history  of  rheumatism.  In  May  he  also  had  a  defi- 
nite attack  of  pericarditis  with  pericardial  friction  from  which  he  slowly 
and  incompletely  recovered.  In  August  ascites  developed,  and  for  this 
he  was  tapped  on  more  than  one  occasion  between  August  and  Decem- 
ber, and  a  large  and  smooth  liver  was  then  felt.  At  the  end  of  Decem- 
ber the  precordial  region  was  noticed  to  be  prominent  and  there  was 
exaggerated  systolic  pulsation  with  systolic  recession  of  the  intercostal 
spaces.  The  area  of  cardiac  dulness  was  enlarged  and  the  heart  sounds 
found  muffled,  but  there  was  no  bruit.  Absence  of  fever  had  been  a 
feature  of  his  illness,  but  at  the  end  of  December  the  temperature  rose 
each  morning  to  100°  to  101°  F.  At  the  end  of  January  he  became 
drow.sy  and  vomited,  then  he  became  unconscious  and  cyanosed. 
There  was  a  slight  hemiplegia  of  the  right  side  and  the  optic  disks  were 
blurred.  Slight  facial  twitching  was  noted  later,  and  he  died  suddenly, 
comatose,  on  January  27th. 

The  necropsy  showed  tuberculous  meningitis,  tuberculous  ulcers  in 
the  intestine,  and  caseating  bronchial  lymph  nodes.  The  pericardium 
was  densely  adherent,  the  heart  not  noticeably  enlarged  and  the  valves 
normal.  There  was  plastic  peritonitis,  and  around  the  liver  a  firm 
inflammatory  capsule.  Except  for  some  adhesions  the  lungs  and  pleune 
were  natural. 

Another  case  under  my  observation,  with  a  history  of  ascites,  ended 
in  the  most  puzzling  manner  with  tuberculous  meningitis,  but,  in  addi- 
tion, the  mitral  valve  and  mitral  ring  were  rigid  with  calcareous  deposits. 
Some  writers  consider  tuberculosis  the  most  important  factor  in  the 
causation  of  multiple  serous  inflammations. 

Malignant  Endocarditis. — Malignant  endocarditis  is  an  occasional 
incident  in  tul)erculosis,  and  is  probably  the  result  of  secondary  infection 
of  the  valves  from  some  suppurating  focus  in  the  lungs  or  bronchial 
lymph  nodes. 


HEART  DISEASE  FROM  INFECTIOUS  DISEASES  755 

HEART  DISEASE  RESULTING  FROM  INFLUENZA. 

The  damage  to  the  myocardium  which  resuUs  from  some  of  the 
epidemics  of  influenza  is  more  often  seen  in  the  elderly;  yet  it  occurs 
also  in  childhood,  and  even  in  infancy,  as  has  been  described  by  Forch- 
heimer  in  Jacobi's  Festschrift. 

Symptomatology. — The  symptoms  are  essentially  those  of  acute  cardiac 
dilatation,  followed  by  a  more  or  less  prolonged  stage  of  myocardial 
weakness.  Among  the  symptoms  which  occur  in  acute  cases,  Forch- 
heimer  lays  stress  upon  the  rapid  breathing,  resembling  that  seen  in 
acute  edema  of  the  lungs.  I  would  also  emphasize  the  great  nervous 
depression,  sometimes  quite  out  of  proportion  to  the  severity  of  the 
cardiac  lesion.  The  pulse  is  rapid  and  irregular  and  low  in  tension. 
As  a  rule,  there  is  no  bruit,  but  there  is  dilatation,  with  feeble  cardiac 
sounds.  I  am  indebted  to  Dr.  Cheadle  for  calling  my  attention  to  cases 
of  influenzal  heart  disease  in  childhood,  in  which  there  develops  a 
rasping,  basal  systolic  murmur,  curiously  superficial  and  clearly  audible 
over  the  sternum  at  the  level  of  the  aortic  cartilage.  Whether  this  is 
of  valvular  or  pericardial  origin  is  uncertain.  These  children  show 
symptoms  of  myocardial  weakness  lasting,  sometimes,  for  years  after 
the  attack  of  influenza. 

Endocardial  and  pericardial  affections  are  rare,  but  Austin  and  others 
have  recorded  examples  of  them. 

Diagnosis. — Unless  there  is  a  history  of  an  attack  of  influenza,  this 
is  not  easy.  The  condition  is  liable  to  be  mistaken  for  rheumatism,  for 
there  are  obscure  pains,  a  sore  throat,  and  dilatation  of  the  heart.  The 
abrupt  onset,  high  fever,  nervous  prostration,  and  absence  of  arthritis 
and  valvular  disease  are  suggestive  of  influenza. 

Prognosis. — The  prognosis  is,  on  the  whole,  good,  but  the  weakness 
of  the  heart,  even  at  this  age,  may  be  very  persistent  and  resist  treat- 
ment for  some  years.     ^Vhen  infants  are  attacked  the  outlook  is  grave. 

Treatment. — It  is  highly  necessary  in  such  cases  to  insist  upon  rest, 
immediate  and  complete.  The  dilatation  should  be  treated  upon  the 
lines  indicated  under  Diphtheria  (q.  v.).  Later,  athletic  exercises  will 
have  to  be  curtailed  if  there  remain  shortness  of  breath,  palpitation,  and 
irregularity  of  the  action  of  the  heart. 

HEART    DISEASE  RESULTING  FROM  CONGENITAL  SYPHILIS. 

It  is  very  doubtful  whether  congenital  syphilis  takes  anything  but  a 
very  secondary  place  in  the  heart  disease  of  childhood.  Gummata  and 
myocarditis  have  been  noted  in  severe  cases  of  congenital  syphilis,  but 
these  are  pathological  curiosities.  There  are,  it  is  true,  some  who 
believe  a  considerable  number  of  obscure  cases  of  endocarditis  are  due 
to  this  disease,  but,  for  my  part,  I  am  doubtful  of  this  and  have  been 
struck  with  the  absence  of  cardiac  affections  in  those  infants  and  children 
who  have  shown  conclusive  evidence  of  congenital  syphiHs. 


'56  DISEASES  OF    THE   HEART   A.\D   BLOODVESSELS 


FUNCTIONAL  DISORDERS. 

This  i.s  an  ill-defined  grouj),  for,  when  one  remembers  the  lesson  of 
diphtheria,  one  hesitates  to  apply  the  term  functional  to  those  eases  of 
palpitation,  irregularity,  and  disturbed  action  of  the  heart  which  some- 
times follow  infectious  diseases.  The  most  definite  exam])les  are  those 
which  result  from  dyspepsia,  with  dilatation  of  the  stomach  and  constipa- 
tion, and  they  are  especially  apt  to  occur  in  the  children  of  nervous  and 
dyspej)tic  parents.  In  these  cases  the  j)ulse  is  irrej:;idar  and  the  heart 
easily  excit(>d.  Complaints  of  palpitation  and  pain  are  not  so  usual  lus 
a  fijeneral  listlessness  and  breathlessness  on  slight  exertion,  but  such 
children  have  attacks  in  which  the  face  is  flushed  and  the  action  of  the 
heart  irregular,  rapid,  and  tumultuous.  The  cardiac  impulse  is  more 
than  usually  visible,  although  tlu>  cardiac  area  may  be  v(>ry  slightly  or 
not  at  all  incrcjised.  There  is,  as  a  rule,  no  murmur,  although  it  is  not 
uncommon  to  meet  with  a  faint  systolic  murmur,  which  is  audible  at 
the  horizontal  level  of  the  nipple,  and  internal  to  it.  Da  Costa  has 
directed  attention  to  certain  idiopathic  cases  of  cardiac  irregularity 
which  appear  to  run  in  families,  and  which  apparently  improve  as 
adult  life  is  reached. 

Functional  bruits  are  not  so  common  in  childhood  as  at  and  after 
puberty,  but  they  are  met  with  in  anemic  children  and  in  anemic, 
rickety  infants.  Deformity  of  the  chest  resulting  from  rickets,  or  spinal 
caries,  or  from  obstructions  in  the  upper  air  passages  will  also  give  rise 
to  cardiac  murmurs;  and,  if  the  upper  lobe  of  the  left  lung  is  retracted, 
such  murmurs  in  the  pulmonary  region  may  be  loud  and  rasping. 

Diagnosis. — It  is  often  difficult  to  decide  whether  a  bruit  is  functional 
or  organic.  A  wide  survey  of  the  case  must  be  taken,  the  heart  examined 
most  carefully  for  evidence  of  hypertrophy,  a  history  of  rheumatism 
incjuired  for,  and  cyanosis  or  slight  clubbing  of  the  extremities  searched 
for ;  it  is  often  necessary  to  see  the  case  more  than  once  before  an  opinion 
that  is  of  any  value  can  be  given. 

These  functional  bruits  are  often  modified  by  the  position  of  the 
patient  and  by  the  respiratory  movements,  but  neither  of  these  facts 
is  conclusive  proof  of  their  functional  nature. 

It  is  well  to  ac(|uaint  the  parents  with  the  fact  that  there  is  some 
weakness  of  the  heart  of  a  passing  nature. 

Treatment. — The  treatment  is  usiudly  satisfactory.  Indigestion,  con- 
stipation, and  anemia  are  corrected.  Quiet  regular  habits  and  plain 
meals  are  necessary,  and  late  hours  should  not  be  permitted. 

When  the  digestion  is  improved,  mild  tonics,  usually  prescribed  with 
a  saline  a])erient,  are  beneficial.  The  town-bred,  nervous  caricature 
of  a  child  will  derive  much  benefit  from  running  wild  in  the  country, 
but  this  prescription  needs  care.  Such  children  will  not  digest  the 
rough  food  often  met  with  in  farm-houses,  and  the  physician  will  be 
greatly  blamed  if  this  life  is  thought  by  the  parents  to  be  too  rough  for 
their  delicate  child. 


THE  HEART  IN  RENAL   DISEASE  757 

Athletics  in  Heart  Disease. — In  this  connection  it  may  be  service- 
able to  write  a  few  words  upon  the  subject  of  athletics.  If  one  can  judge 
by  the  regulations  that  are  sometimes  made,  I  do  not  think  that  a 
knowledge  of  heart  disease  implies  any  knowledge  of  athletic  pursuits. 
Possibly,  it  may  seem  a  trivial  matter  to  be  writing  upon  cricket  and 
football  in  a  solemn  work  such  as  this,  but  the  questions  that  arise  are 
neither  easy  nor  unimportant.  Schoolmasters  of  wide  experience  will 
point  out  that  it  is  very  detrimental  to  interfere  unnecessarily  with  a  boy's 
athletics,  and  speak  of  the  evils  that  may  result  as  far  outweighing  the 
danger  that  it  is  sought  to  avoid.  Boy  is  a  pitiless  production,  and  can- 
not understand  delicacy  and  feebleness.  It  is,  I  think,  as  a  general  rule, 
a  mistake  to  send  a  boy  who  has  a  damaged  heart  to  a  big  school  where 
athletics  are  compulsory.  But  there  are  many  cases  on  the  border-hne; 
these  are  the  troublesome  ones,  and  it  is  then  that  a  practical  acquaint- 
ance with  the  various  games  is  useful. 

All  com'petitive  exercises  are  dangerous  to  feeble  hearts — I  mean  by 
this  foot-racing,  boat-racing,  cycle-racing,  cross-country  runs,  boxing, 
and  so  on — for  when  there  is  competition  the  "thoroi;gh-bred"  will  try 
to  better  his  best.  Here  lies  the  mischief,  and  irreparable  damage  may 
be  done  in  this  way  to  a  heart  which  would  benefit  from  ordinary 
exertion.  Acute  dilatation  of  the  heart  may  result  from  girls  dancing 
too  frequently  and  for  too  long  periods  of  time. 

Football  is  also  dangerous  because  of  the  sudden  exertion  and  strain 
inseparable  from  it.  Cricket  is  more  suitable,  baseball  less  so.  Fives 
and  lawn-tennis  are  well  enough,  if  the  boy  is  not  permitted  to  enter 
for  competitive  struggles  for  cups  and  other  trophies.  Racquets,  if 
played  at  all  well,  is  a  trying  game.  Golf  is  a  valuable  open-air  amuse- 
ment. Again,  drilling  and  graduated  gymnastic  exercises,  though  hardly 
exhilarating,  are  useful,  and  may  prepare  the  way  for  the  more  active 
games. 

THE  HEART  IN  RENAL  DISEASE. 

Apart  from  endocarditis  and  pericarditis  complicating  nephritis,  renal 
disease  throws  a  great  strain  upon  the  heart. 

The  first  result  is,  as  a  rule,  dilatation  of  the  left  ventricle,  and  this 
dilatation  may  be  slight  or  severe. 

Examination  will  show  that  the  pulse  is  quickened,  low  in  tension,  and 
sometimes  irregular.  The  impulse  is  diffuse,  the  area  of  cardiac  dulness 
is  increased  to  the  left,  and  the  first  sound  is  altered  in  character.  At 
first  there  is  prolongation,  and  later  shortening  of  its  duration.  The 
rhythm  of  the  heart  becomes  tic-tac,  and  both  sounds  may  be  redupli- 
cated. Eclampsia  is  liable  to  supervene  when  the  heart  is  dilated  and 
the  tension  low.  Later,  hypertrophy  of  the  left  ventricle  develops 
(Fig.  161),  and  the  character  of  the  pulse  alters;  the  wave  is  now  pro- 
longed and  not  easily  compressible,  and  the  arterial  wall  is  slightly 
thickened.  It  is  only  in  very  exceptional  cases  that  advanced  arterio- 
capillary  fibrosis  and  hypertrophy  of  the  heart  are  met  with  in  childhood. 


758 


DISEASES  OF   THE   HEART   AM)   BLOODVESSELS 


Treatment. — Treatment  consists  in  arrestin(f,  if  possible,  the  renal 
disea.se.  Rest  is  essential  when  there  is  dilatation.  Altlion<,di  there  is 
very  rarely  any  anxiety  of  a  bloodvessel  gixing  way  from  high  arterial 
tension,  still*,  the  tension  of  the  pulse  should  be  kept  at  a  judicious  mean 
by  an  occasional  dose  of  calomel  and  saline  and  by  the  restriction  of 
meat  in  the  diet.  The  anemia  should  be  corrected  by  giving  iron 
combined  with  a  saline  aperient. 


Fig.  161 


Cardiac  hypertrophy.  A  section  across  the  ventricles,  showing  great  hypertrophy  of  the  left  one, 
the  result  of  chronic  nephritis  in  a  child.  (From  the  Museum  of  the  Hospital  for  Sick  Children, 
Great  Ormond  Street.) 


DISEASES  OF  THE  ARTERIES. 


ANEURYSM. 

Diseases  of  the  arteries  are  rare  in  childhood,  aneurysm  being  one  of 
the  most  important.  Each  case  of  aneurysm  that  I  have  seen  myself 
has  been  of  a  different  type.  One  was  traumatic  in  origin,  another  was 
the  result  of  malignant  endocarditis,  and  a  third  was  of  doubtful  nature. 

The  traumatic  case  was  that  of  a  boy  who  fell  on  his  head  and 
damaged  the  right  internal  carotid  artery  as  it  entered  the  carotid 
canal.  The  aneurysm  leaked  into  the  throat  and  the  child  died  after 
repeated  hematemesis. 

The  case  due  to  malignant  endocarditis  was  a  very  striking  one. 
The  boy  had  been  the  victim  of  severe  rheumatic  carditis  on  more  than 
one  occasion,  and  was  now  under  treatment  because  of  a  swelling  in 
the  right  thigh,  over  the  course  of  the  femoral  artery.  This  was  clearly 
an  aneurysm,  and  there  was  evidence  of  infarction  in  other  organs;  this 
aneur^'sm  reached  an  enormous  size,  and  caused  terrible  pain  from  the 
tension  in  the  surrounding  ti.ssues. 

Death  occurred  from  cardiac  failure,  and  the  aneurysm  which  had 


DISEASES  OF   THE   ARTERIES  759 

originated  from  the  common  femoral  artery  was  discovered  to  have 
formed  a  false  sac  wliich  occupied  all  the  upper  parts  of  the  thigh. 

The  third  case  noted  in  the  Tramactions  of  the  Pathological  Society 
of  London,  vol.  xlvii.  p.  24,  by  IMr.  Jackson  Clarke,  was  a  girl,  aged 
ten  years,  who  was  under  the  care  of  Dr.  Lees  at  St.  INIary's  Hospital. 
This  child  had  an  aneurysm  in  the  left  axilla  and  another  in  the  right 
buttock.  The  axillary  aneurj-sm  leaked  and  the  child  died  suddenly. 
The  necropsy  showed  multiple  aneurysms  upon  the  primary  and 
secondary  branches  of  the  coronary  arteries;  there  was  also  a  thickened 
mitral  valve,  but  no  recent  disease.  Congenital  syphilis  was  suggested 
as  a  possible  explanation. 

Jacobi,  Sanne,  Parker,  Keen,  and  others  have  recorded  cases  of 
aneurysm  which  serve  to  remind  us  that  even  the  arteries,  which  are 
the  most  trustworthy  structures  in  childhood,  may  sometimes  fail. 
There  may  be  atheroma,  or  malignant  endocarditis,  or,  as  Eppinger's 
case  would  seem  to  show,  a  congenital  lack  of  elastic  tissue.  Again, 
small  pulmonary  aneuiysms  are  sometimes  met  with  in  tuberculous 
disease  of  the  lungs  with  cavity  formations. 


OTHER  ARTERIAL  DISEASES. 

Acute  Arteritis. — Acute  arteritis  has  also  been  described,  and  by 
French  writers  a  good  deal  has  been  written  upon  its  occiirrence  in  acute 
rheumatism.  Rabe  gives  a  detailed  account  (La  presse  medicale,  1902) 
of  this  process  in  the  intrapericardial  arteries. 

I  have  never  met  ^^ith  a  conclusive  case  of  acute  arteritis  in  a  child, 
though  perivascular  fibrosis  is  common  in  the  regions  of  rheumatic 
lesions,  as  is  the  case  in  other  infections.  In  malignant  endocarditis 
the  inflammation  may  spread  to  the  commencement  of  the  aorta,  and 
small,  white  patches  of  inflammation  may  also  be  sometimes  seen  in 
simple  rheumatism.  These  differ  from  somewhat  similar  fatty  patches 
which  are  occasionallv  noticed  in  necropsies  upon  anemic  children. 

Acute  Septic  Arteritis  sometimes  occurs  in  pyemia. 

General  Arteriosclerosis. — General  arteriosclerosis  is  also  rare, 
but  in  those  unusual  cases  of  granular  kidney  in  childhood  it  may  reach 
a  high  degree,  and  the  retinal  vessels  may  then  show  all  the  changes 
which  are  so  well  recognized  in  the  disease  in  adults. 


SECTION   IX. 
DISEASES  OF  THE  GENITOURINARY  SYSTEM. 

By  CHARLES  G.  JENNINGS,  M.D. 


CHAPTER  XXXI. 

URETHRITIS— VULVOVAGINITIS— DISEASES  OF  THE  BLADDER- 
DISEASES  OF  THE  KIDNEYS. 

URETHRITIS  IN  THE  MALE. 

Infection  of  the  urethra  is  occasionally  seen  in  young  boys,  and 
more  rarely  in  male  infants.  Infection  may  be  by  the  organisms  of  pus, 
simple  urethritis,  or  by  the  gonococcus,  gonorrheal  urethritis. 

Simple  Urethritis. — Pus  organisms  may  invade  the  urethra  from  an 
infected  prepuce.  Phimosis  and  uncleanliness  are  the  chief  etiological 
factors,  A  balanitis  usually  precedes  the  urethritis.  Pus  organisms 
very  rarely  invade  the  deep  urethra;  so  the  inflammation  is,  as  a  rule, 
confined  to  the  fossa  navicularis  or  the  first  part  of  the  anterior  urethra. 

The  prepuce  is  tender,  swollen,  and  red,  and  the  preputial  canal  and 
the  meatus  are  bathed  in  pus.  Some  pain  on  micturition  is  usually 
present.  Retraction  of  the  prepuce  is  impossible.  With  cleanliness  and 
appropriate  treatment  a  simple  urethritis  promptly  subsides.  It  is 
obstinate  when  a  balanitis  and  a  tight  prepuce  complicate  it.  Thorough 
cleanliness  is,  under  these  circumstances,  difficult,  and  often  can  be 
obtained  only  by  slitting  up  the  prepuce.  Careful  irrigation  of  the 
preputial  opening  several  times  daily  with  a  mild  antiseptic  solution,  such 
as  one  of  weak  boric  acid,  and  the  removal  of  all  irritating  secretions, 
are  the  important  therapeutic  indications.  In  simple  urethritis,  injec- 
tions into  the  urethral  canal  are  rarely  necessary.  The  administration 
of  alkalies  is  all  that  is  usually  required.  Occasionally  santal,  salol, 
or  oil  of  wintergreen  internally  will  be  needed  to  control  the  patho- 
logical process  in  the  urethra. 

Gonorrheal  Urethritis. — Gonorrheal  urethritis  is  not  infrequently 
seen  among  the  children  of  the  poor  and  uncleanly.  Infants  are  rarely 
infected.  Boys  over  the  age  of  six  years  are  the  most  frequent  subjects. 
Infection  may  be  by  venereal  contact  with  an  infected  member  of  the 
family.    Pederasty  is  occasionally  the  means  of  infection. 

(761) 


762  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

The  (Imionstration  of  the  o;()n()C(K'('us  in  the  urctlinil  discharge  is 
tlie  only  certain  nictiiod  of  diagnosis  of  a  specific  from  a  simple  nrethritis. 
To  guide  prognosis  and  therapeusis,  microscopic  examination  of  the 
discharge  should  always  be  made. 

Symptomatology. — Symptoms  of  a  sp(>cific  urethritis  are  usually  more 
severe  than  in  the  simple  form.  Pain  and  swelling  often  are  very 
marked.  The  discharge  is  abundant  and  com])osed  of  thick,  creamy 
pus.  A  long,  tight  prepuce  is  an  embarrassing  complication,  rendering 
the  necessary  cleanliness  almost  impossible  and  aggravating  the  urethral 
inflaTumation.  The  gonorrhea  of  boys  is  frecjuently  complicated  by 
epididymitis  and  prostatitis;  cystitis  is  not  so  common  as  in  the  adult. 
Orchitis,  gleet,  and  stricture  are  very  rare.  The  last  complication  may, 
however,  be  overlooked  owing  to  the  age  of  the  patient. 

In  boys,  constitutional  symptoms  are  not  so  severe  as  in  men,  and 
invasion  of  the  joints,  the  heart,  and  other  remote  organs  is  almost 
unknown,    'i'he  carelessness  of  the  child  rather  favors  conjunctivitis. 

Treatment. — The  treatment  of  gonorrhea  in  a  boy  is  practically  the 
same  as  in  the  adult.  Cleanliness  and  the  protection  of  remote  mucous 
membranes  by  a  proper  dressing  of  the  parts  are  imperative.  A  tight 
prepuce  and  a  l)alanitis  may  demand  frecjuent  preputial  irrigation  and, 
perhaps,  operation,  although  circumcision  during  the  height  of  a  balanitis 
is  not  often  wise.  Urethral  injections  are  not,  as  a  rule,  practicable, 
and  in  ordinary  cases  need  not  be  made.  They  cannot,  of  course,  be 
entrusted  to  the  patient.  In  any  case,  they  had  better  be  postponed 
until  the  stage  of  decline.  In  the  acute  stage,  rest  in  bed  and  a  properly 
regulated  simple  milk  and  light  diet,  abundance  of  fluid,  and  the  admin- 
istration of  alkalies  constitute  an  important  part  of  the  treatment. 
After  a  few  days,  santal,  0.3  c.c.  (5  min.),  every  three  hours;  oil  of 
wintergreen,  O.bS  c.c.  to  0.3  c.c.  (2  to  5  min.),  three  times  daily;  or 
salol,  0.3  gm.  (5  gr.),  every  three  hours  may  be  given.  Infection  of  the 
deep  urethra  and  other  complications  demand  the  same  treatment  as 
in  adult  life. 


VULVOVAGINITIS. 

According  to  its  etiology,  Vulvovaginitis  is  divided  into  simple  catarrhal 
vulroraf/lnHis  and  r/ouorrlicaJ   ni])'(>vaginififi. 

Simple  Catarrhal  Vulvovaginitis. — Simple  catarrhal  vulvovaginitis 
occurs  most  frc'cjuently  in  girls  between  the  ages  of  three  and  seven 
years.  It  is  frequently  seen  even  in  early  infancy.  Children  of  im- 
hygienic  households,  those  suffering  from  malnutrition  and  anemia,  or 
debilitated  by  acute  or  chronic  diseases,  are  the  most  frequent  subjects. 
It  occurs  fre(juently  as  a  complicating  local  infection  in  the  exanthemata, 
particularly  measles  and  scarlet  fever.  The  disease  is  very  common  in 
institutions  and  where  children  are  segregated,  and  often  occurs  there 
in  epidemics.  Under  these  circumstances  it  is  transmitted  by  direct 
contact,  or  through  the  medium  of  infected  nurses,  articles  of  clothing, 


VUL  VO  VA  GINITIS  763 

or  instruments.  In  common  with  catarrhs  of  other  mucous  membranes, 
it  may  result  from  exposure  to  cold  and  wet,  especially  in  vitiated  states 
of  the  system.  Traumatism,  masturbation,  foreign  bodies  or  parasites 
in  the  vagina  or  urethra  are  occasional  causes. 

Pathology. — The  disease  is  the  result;  of  the  invasion  of  the  mucous 
membrane  of  the  vulva  or  vagina  and  urethra  by  one  or  more  of  the 
various  pus-producing  organisms.  The  colon  bacillus  is  a  frequent 
offender.  The  mucous  membranes  of  the  healthy  and  cleanly  child 
resist  infection.  Diminution  of  the  resistance  by  one  of  the  above- 
mentioned  predisposing  causes  is  usually  a  necessary  antecedent  to  the 
development  of  the  disease. 

Symptomatology. — Simple  vulvovaginitis,  as  stated  above,  is  most  fre- 
quently seen  in  anemic,  debilitated  children.  In  such  subjects  it  appears 
as  a  mild  subacute  catarrh  with  a  vulvovaginal  discharge  that  is  white  or 
yellowish  white.  There  is  some  redness  and  swelling.  The  vulva  is, 
particularly,  the  seat  of  the  pathological  process,  and  the  inflammation 
frequently  extends  to  the  skin  over  the  vulva  and  between  the  thighs. 
There  are  no  constitutional  symptoms.  Pain  on  micturition  in  the 
subacute  variety  is  not  usually  present.  Older  children  sometimes  com- 
plain of  soreness  on  walking. 

In  the  acute  and  more  severe  cases  all  the  symptoms  of  inflammation 
are  increased.  The  discharge  is  a  thick,  yellowish  pus  that  can  be 
demonstrated  to  come  from  the  vulva,  vagina,  urethra,  and  the  cervix 
uteri.  Excoriations  of  the  mucous  membrane  and  superficial  ulcerations 
are  common.  The  discharge  forms  crusts  at  the  orifice  of  the  vulva, 
and  the  labia  are  adherent.  The  parts  are  red,  swollen,  and  edematous, 
and  there  is  often  much  local  discomfort. 

A  simple  vulvovaginitis  usually  remains  a  local  process.  Remote 
infections  are  rare.  The  communicating  lymph  nodes  are  occasionally 
swollen  and  tender,  but  rarely  an  abscess  forms.  In  colon  bacillus 
infection,  particularly,  cystitis  may  result.  I  have  seen  one  case  in 
which  a  fatal  termination  followed  successive  infection  by  this  organism 
of  the  vulva,  bladder,  and  pelvis  of  the  kidney. 

Gonorrheal  Vulvovaginitis.^ — Bacteriological  investigation  of  vulvo- 
vaginitis by  many  observers  has  shown  that  a  large  percentage  of  all 
the  cases  of  the  disease  are  the  result  of  gonococcic  infection.  Among 
the  negroes  of  the  South,  in  institutions,  in  the  tenement  districts,  and 
wherever  uncleanly  children  associate  intimately,  the  gonococcus  appears 
to  be  the  most  common  infecting  organism. 

As  in  the  adult  female,  gonorrheal  infection  in  the  child  may  pursue 
a  mild  or  latent  course,  and  numerous  observations  show  that  exten- 
sive epidemics  have  been  started  by  infection  from  children  suffering 
from  an  apparently  trivial  vulvovaginal  catarrh.  As  Huber  has  pointed 
out,  it  is  often  almost  impossible  to  trace  the  source  of  an  institution 
epidemic.  Transmission  of  the  disease  rarely  takes  place  by  venereal 
contact;  infection  is  usually  indirect,  conveyed  by  towels,  bed-linen, 
instruments,  by  nurses,  from  parents,  by  contact  with  soiled  floors, 
etc.     Ninety  per  cent,  of  the  mothers  of  44  cases  studied  by  Pott  were, 


764  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

found  to  l)c  .sufforiiifj;  from  k'ncorrhea.  Where  it  lias  been  definitely 
tnurd,  the  })c'riod  of  incuhatioii  is  about  three  days. 

Ssanptomatology. — While,  as  a  rule,  fi;onococcic  vulvovaginitis  pursues 
a  more  active  course  than  a  vaginitis  due  to  a  simple  infection,  there 
is  nothing  uniformly  characteristic  in  its  clinical  history.  In  the  more 
severe  cases  there  are  the  evidences  of  a  severe  inflammation  of  all  the 
mucous  membranes  of  the  lower  genitourinary  tract.  The  vulva  and 
vagina  are  bathed  with  a  thick,  purulent  secretion.  Holt  states  that  the 
mucous  membrane  of  the  cervix  is  almost  invariably  involved.  Urethritis 
is  frequent,  but  does  not  give  rise  to  such  marked  symptoms  as  in  the 
adult.  The  labia  are  swollen  and  glued  together  with  secretion,  and 
the  inflammation  extends  for  some  distance  over  the  neighboring  skin. 
The  inguinal  lymph  nodes  are  frequently  enlarged  and  tender;  rarely 
a  suppurating  bubo  results.  The  glands  of  Bartholini  are  often  enlarged 
and  occasionally  suppurate.  During  the  first  few  days  of  severe  cases 
there  may  be  slight  fever  and  constitutional  symptoms,  although,  as 
Holt  remarks,  the  absence  of  constitutional  symptoms  is  one  of  the 
most  striking  points  of  difference  between  gonorrhea  in  the  child  and 
in  the  adult. 

The  course  and  duration  of  gonorrheal  vulvovaginitis  is  exceedingly 
variable.  Under  favorable  conditions  complete  recovery  may  take  place 
in  from  four  to  six  weeks.  As  in  the  adult,  a  specific  vaginitis  may 
persist  for  months,  and  as  a  so-called  latent  gonorrhea  the  child  may 
be  a  source  of  infection  for  an  indefinite  period.  Relapses  after  apparent 
recovery  are  frecjuent. 

It  appears  that  children  resist  more  vigorously  than  adults  remote 
gonococcic  infection.  The  literature  of  the  last  few  years,  however, 
makes  it  certain  that  these  infections  are  much  more  frequent  than  was 
formerly  supposed,  and  that  the  remote  eftects  of  a  gonorrheal  vulvo- 
vaginitis are  often  of  the  gravest  character.  In  addition  to  the  invasion 
of  the  neighboring  lymph  nodes,  the  infection  may  involve  the  whole 
length  of  both  the  genital  and  the  urinary  tracts.  Cystitis,  pyelitis, 
and  pyelonephritis  are  occasional  results.  A  freciuent  result  of  a  long- 
standing vulvovaginitis  is  atresia  of  the  vagina.  Bokai  has  reported 
39  such  eases,  and  Jacobi  mentions  it  as  frequently  observed. 
In  atresia  from  this  cause  the  adhesions  are  superficial  and  easily 
separated  by  the  finger.  In  all  severe  cases  the  endometrium  is  invaded. 
Salpingitis,  oophoritis,  and  peritonitis  have  been  noted,  and  there  may 
result  any  of  the  pelvic  complications  so  frecjuently  observed  in  adult 
life — a  very  important  matter  when  considered  in  relation  to  the  devel- 
opment of  the  diseased  organs  and  to  future  pregnancies. 

Gonococcic  peritonitis,  from  infection  through  the  Fallopian  tubes, 
is  not  luicommon;  40  cases  of  this  character  have  been  collected  from 
current  literature.  The  frequency  of  this  form  of  infection  of  the 
peritoneum  should  put  the  physician  on  his  guard  in  every  case  of 
general  peritonitis  in  a  young  girl.  The  possibility  of  confusing  this 
condition  with  an  appendicitis  is  manifest.  '^I'he  recognition  of  the 
condition  is  of  particular  importance  from  a  therapeutic  point  of  view, 


VUL  VO  VA  GINITIS  7f;5 

as  the  prognosis  is  so  favorable  under  laparotomy  and  peritoneal 
irrigation. 

Huber  calls  attention  to  a  gonococcic  proctitis  as  a  not  infrequent 
complication  of  vulvovaginitis,  and  he  looks  upon  a  lingering  infection 
of  the  rectum  as  one  of  the  frequent  sources  of  contagion. 

Arthritis  as  a  complication  of  gonorrheal  vulvovaginitis  is  not  common. 
Koplik  has  met  with  three  cases;  Acker  has  reported  one,  in  a  child  two 
years  of  age.  The  possibility  of  infection  of  the  conjunctiva,  although  it 
does  not  frequently  occur,  should  always  be  borne  in  mind. 

Diagnosis. — The  demonstration  of  the  gonococcus  in  the  discharge  is 
the  only  certain  means  of  differentiating  a  simple  from  a  specific  vulvo- 
vaginitis. In  the  interests  of  the  patient  and  her  associates,  this  exami- 
nation should  always  be  made.  In  the  absence  of  bacteriological 
demonstration,  all  severe  cases  of  vulvovaginitis  should  be  looked  upon 
as  probably  due  to  gonococcus  infection.  When  several  cases  occur  in 
a  family,  in  a  neighborhood,  or  in  an  institution,  the  chances  are  strongly 
in  favor  of  gonococcic  origin.  The  presence  of  a  urethritis,  invasion 
of  the  urethra,  the  glands  of  Bartholini  and  the  upper  genitourinary 
tract  point  to  gonococcic  infection. 

Prognosis. — Simple  vulvovaginal  catarrh  pursues  a  much  shorter  and 
more  benign  course  than  when  due  to  gonococcic  infection.  With 
judicious  treatment  recovery  will  take  place  in  from  two  to  four  weeks, 
although  often  the  case  is  prolonged  on  account  of  the  difficulties 
encountered  in  the  application  of  local  medication.  In  simple  vulvo- 
vaginitis complications  are  rare  and  are  not  apt  to  be  of  a  serious 
natu.re. 

In  gonorrheal  vulvovaginitis  the  progress  is  much  less  favorable. 
Under  the  most  careful  treatment  cases  are  obstinate  and  often  are 
prolonged  over  a  period  of  weeks  or  months.  Serious  and  even  fatal 
complications  not  infrequently  occur.  The  remote  effects  upon  the 
health  of  the  patient  may  be  unfortunate. 

Treatment. — As  the  disease  is  spread  by  contagion,  prophylaxis  is  of 
the  greatest  importance.  In  institutions  and  in  families  isolation  of  the 
patient  is  essential,  and  the  most  scrupulous  care  is  necessary  to  prevent 
the  spread  of  the  disease.  The  experience  of  Huber  and  others  shows 
how  difficult  it  is  in  institutions  to  control  the  spread  of  the  disease 
when  it  has  once  gained  a  foothold.  Napkins,  sheets,  towels,  and  all 
utensils  should  be  thoroughly  sterilized. 

For  a  simple  vulvovaginitis  local  treatment  consists  in  absolute 
cleanliness  and  the  use  of  mild  astringent  injections.  Twice  or  three 
times  a  day  the  child  should  be  placed  upon  a  surgical  pad  or  rubber 
sheet,  and  the  buttocks,  labia,  and  all  external  parts  thoroughly  bathed 
with  soap  and  water  and  irrigated  with  a  1 :  5000  solution  of  corrosive 
sublimate  or  a  1:  100  solution  of  carbolic  acid.  An  antiseptic  sitz- 
bath  accomplishes  an  excellent  puiijose.  Following  the  ex-ternal  cleans- 
ing, an  injection  from  a  fountain  syringe  of  from  one  to  two  pints  of 
a  solution  of  boric  acid,  1  :  500,  or  carbolic  acid,  1  :  200,  may  be  used. 
After  the  injection  the  parts  should  be  thoroughly  dried  and  anointed 


766  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

with  cold  civain  or  va.st'lin.  A  pad  of  .sterile  <,'au/>e  should  be  placed 
over  the  vulva  and  held  in  position  l)y  a  napkin.  With  the  decline  of 
the  acute  symptoms  astringent  injections  may  he  used;  tannin  or  alum 
solution,  5  per  cent.;  sulphate  of  zinc  or  nitrate  of  silver,  1  per  cent., 
are  efficient. 

The  general  health  demands  attention,  and  conditions  of  mal- 
nutrition or  anemia  should  receive  appropriate  treatment. 

In  the  gonorrheal  infections  the  same  general  ])laii  should  be  carried 
out;  in  the  cases  in  which  the  inflammation  is  active  the  hot  sitz-bath 
will  afford  great  relief.  In  all  severe  cases  the  ])atient  should  be  kept  in 
bed.  Following  the  cleansing  irrigation,  the  vulva  and  vagina  should 
be  thoroughly  douched  with  a  solution  of  one  of  the  proteid  salts  of 
silver;  protargol  and  argyrol  are  the  most  efficient.  A  solution  of 
argyrol,  1  :  200,  may  be  used  two  or  three  times  a  day  for  the  first 
week  or  ten  days;  after  this  the  argyrol  may  be  discontinued  and  an 
astringent  injection — sulphate  of  zinc,  1  per  cent. — sul)stituted.  A 
surgical  wick  dressing  with  a  1  to  2  per  cent,  ichthyol  and  a  vulvar  pad  is, 
in  some  cases,  more  efficient  than  douching.  An  occasional  examina- 
tion of  the  secretions  for  the  gonococcus  should  be  made,  to  determine 
the  progress  of  the  disease.  Persistence  in  the  local  treatment  is  neces- 
sary for  comjilete  recovery.  Too  early  discontiimance  very  commonly 
resuhs  in  a  relapse. 

VESICAL  SPASM. 

Vesical  Spasm  is  a  condition  quite  commonly  met  with  in  chiklhood, 
and  more  rarely  in  infancy.  Dysuria  of  Childhood  and  Genital  Irritation 
are  synonyms. 

Etiology. — Vesical  spasm  may  be  one  of  the  results  of  catching  cold, 
or  it  may  occur  as  a  complication  of  any  acute  febrile  disease.  Its 
most  common  cause  is  a  highly  acid  urine  and  it  Is  most  frequently 
seen  when  this  condition  is  a  result  of  chronic  indigestion  w4th  disturbed 
metabolism.  Children  of  the  neurotic  i\\>(^  are  the  most  frecjuent 
sufferers.  It  may  occur  as  a  complication  of  vulvovaginitis  or  urethritis. 
It  is  also  an  occasional  symptom  of  disease  of  adjacent  pelvic  organs. 

Sjnnptoinatology. — The  chief  symptom  of  vesical  spasm  Ls  frequent 
desire  to  urinate,  the  act  of  urination  being  accompanied  by  more  or 
less  severe  pain  and  vesical  tenesmus.  The  pain  attending  micturition 
is  often  intense  and  the  child,  from  the  great  distress,  will  delay  the  act 
as  long  as  possible.  Sometimes  only  a  few  drops  of  urine  are  passed. 
Usually  when  once  the  spasm  is  relieved  the  urine  passes  freely.  Exami- 
nation of  the  urine,  aside  from  the  presence  of  an  excessive  acidity,  is 
negative.    There  is  no  pus  or  blood. 

The  condition  may  be  a  passing  one,  lasting  only  a  few  hours  or  days, 
or,  if  the  cause  be  persistent,  it  may  continue  with  exacerbations  and 
intermissions  over  quite  a  period  of  time.  In  neurotic  children  with 
chronic  indigestion  relapses  are  common,  and  any  trifling  febrile  dis- 
order will  again  light  up  the  difficulty. 


DISEASES  OF  THE  BLADDER  767 

^Yith  a  careful  attention  to  the  diet  and  the  removal  of  the  cause 
recovery  is  usually  prompt. 

Treatment. — The  child  should  be  given  an  abundance  of  a  mildly 
alkaline  water.  Vichy  or  one  of  the  lithia  waters  answers  an  excellent 
purpose.  Tincture  of  belladonna  or  tincture  of  hyoscyamus,  0.03  c.c. 
(5  drops),  four  times  a  day,  may  be  given.  A  hot  sitz-bath  or  hot- water 
applications  over  the  pubes  and  between  the  thighs  will  often  give 
immediate  relief  to  the  distress.  The  diet  should  be  simple  and  non- 
stimulating,  with  milk  and  cereals  in  predominance. 


ENURESIS. 

In  the  physiological  state  evacuation  of  the  bladder  follows  the 
natural  stimulus  of  a  certain  degree  of  distention  of  the  organ.  An 
afferent  impulse  passes  from  the  terminal  nerves  in  the  bladder  to  the 
cord  and  brain,  which  send  out  efferent  impulses  which  contract  the 
detrusor  urinse  and  inhibit  the  contraction  of  the  sphincter  vesicae. 

In  early  infancy  the  evacuation  of  the  bladder  is  purely  a  reflex  act. 
At  the  age  of  about  eighteen  months,  sooner  or  later,  depending  upon 
the  training  and  also  upon  the  general  health  of  the  child,  vesical  control 
to  a  limited  degree  is  acquired.  After  the  third  year  of  life  the  urine 
may  be  held  for  eight  or  nine  hours  during  sleep  and  for  two  or  three 
hours  when  awake.  Inability  to  control  the  bladder  after  the  third  year 
constitutes  incontinence. 

Etiology. — Incontinence  is  a  s}Tnptom  of  numerous  malformations 
and  of  various  organic  diseases  of  the  brain  and  spinal  cord.  In  this 
article  incontinence  from  these  causes  will  not  be  considered;  they  may 
be  studied  in  the  section  upon  Nervous  Diseases. 

The  ordinary  enuresis  of  childhood  is  a  neurosis.  It  may  have  one 
or  more  of  several  etiological  factors,  viz.,  elimination  of  cerebral 
control  over  the  spinal  centres;  increase  of  the  irritability  of  the  centres; 
increase  of  the  irritability  of  the  terminal  filaments  of  the  nerves  of  the 
bladder  or  adjacent  organs ;  changes  in  the  composition  of  the  urine. 

Persistence  of  the  infantile  state,  a  neurotic  inheritance,  neurasthenia, 
anemia,  and  malnutrition,  the  debility  of  convalescence,  are  conditions 
in  which  increased  irritability  of  the  spinal  centres  and  of  the  peripheral 
nerves  is  pronounced. 

Increased  irritability  of  the  terminal  filaments  of  the  nerves  of  the 
bladder  and  adjacent  organs  may  be  caused  by  cystitis,  urinary  calculus, 
an  adherent  or  tight  prepuce,  balanitis  or  vulvovaginitis,  rectal  polyps, 
ascarides,  or  fissure. 

A  latent  chronic  cystitis  from  colon  bacillus  infection  is  an  occasional 
cause.  In  these  cases  the  micro-organism  may  be  demonstrated  in  the 
freshly  passed  urine,  which  may  be  normal  in  appearance  or  but  slighdy 
turbid.     The  only  other  symptom  may  be  the  enuresis. 

A  highly  acid  and  irritating  urine  is  often  present  and  sometimes  a 
cause  of  enuresis.     More  often  it  is  only  an  associated  phenomenon, 


768  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

resultiiif^  from  tlu-  same  muliuitrition  factors  that  determiiu-  tin-  irrita- 
bility of  thr  iH-rvous  mcclianism  of  inictiirilioii.  In  many  cases  the  most 
careful  inves(i<ratioii  fails  to  reveal  an  adecjiiate  cause  for  the  condition. 
Not  infrequently  nocturnal  incontinence  is  met  with  in  cliildren  other- 
wise apparently  in  robust  health.  To  this  class  of  cases  some  writers 
have  confined  the  term  "enuresis." 

Incontinence  occurs  with  ecjual  fre(|uency  in  both  sexes,  both  in 
private  and  institution  practice.  Most  cases  are  seen  durin^^  the  middle 
period  of  childhood. 

Symptomatology. — In  enuresis  pro])er  there  is  no  tlribblin<i;.  The 
bladder,  when  full,  empties  itself  fully  and  freely  without  the  inter- 
vention of  the  will.  The  reflex  mechanism  responds  so  promptly  to  the 
peripheral  irritation  that  the  child,  even  when  awake,  may  have  no 
power  of  postponement.  The  enuresis  may  be  nocturnal^  or  diurnal, 
or  both.  Nocturnal  incontinence  is  the  more  frequent.  There  are  all 
grades  of  severity.  In  some  children  there  is  only  an  occasional  lapse 
under  tiie  influence  of  some  distinct  cause,  while  in  others  the  bed  is 
wet  every  night  and  even  several  times  a  night.  The  condition  may 
continue  to  late  childhood,  and  even  to  puberty.  After  puberty  nocturnal 
emissions  may  rej)lace  the  incontinence. 

Prognosis. — When  incontinence  is  traceable  to  a  distinct  cause  that 
is  removable  the  prognosis  is  good  for  prompt  relief.  While  some  cases 
quickly  respond  to  medical  treatment,  a  large  number  rec|uire  patience 
and  persistence  over  a  number  of  months  or  years.  The  condition  in 
any  case  will  be  more  difficult  to  overcome  in  proportion  to  the  length 
of  time  it  has  continued. 

Treatment. — If  a  cause  for  the  trouble  can  be  foimd  it  should  be 
removed.  Adherent  })repuce,  phimosis,  narrow  meatus,  chronic  latent 
cystitis,  vesical  calculus,  hyperacid  urine,  ascarides,  vulvovaginitis,  rectal 
diseases — all  should  be  sought  for  and,  if  present,  receive  ])roper  treat- 
ment. Circumcision  is  a  measure  usually  advised  and  carried  out,  but 
it  must  be  confessed  that  alone  it  rarely  influences  the  condition.  With  a 
redundant,  tight  prepuce  it  is  probably  an  important  preliminary  treat- 
ment. Remote  local  causes  of  heightened  reflex  irritability,  such  as 
tonsillar  h\^)ertrophy  and  adenoids,  should  receive  attention. 

Treatment  of  the  general  condition  of  the  patient  is  essential.  Anemia, 
malnutrition,  constipation,  and  chronic  indigestion  should  be  treated 
with  appropriate  tonics,  a  careful  diet  and  an  out-of-<loor,  simple  life, 
free  from  the  mental  worry  of  school  competition.  W'ithout  attention 
to  these  points,  any  medical  treatment  is  unavailing. 

The  correction  of  dietetic  errors  is  essential  in  every  case.  Sweets 
and  pastry,  hot  breads,  cake,  indigestible  meats,  tea  and  coffee  should 
be  prohibited.  An  excess  of  uncooked  fruit  will  often  keep  up  a 
chronic  intestinal  indigestion.  No  food  should  be  allowed  between 
the  regular  meals  except  a  half-glassful  of  milk.  A  light  supper  and 
not  more  than  one  glassful  of  fluid  should  be  given  with  it.  No  liquid 
should  be  taken  after  supper.  On  rising  the  child  may  be  given  a 
quick,  cold  sponge  bath  followed  by  a  vigorous  rub. 


DISEASES  OF  THE  BLADDER  769 

The  specific  treatment  for  the  direct  control  of  the  enuresis  should 
begin  with  tincture  of  belladonna,  0.06  c.c.  (1  drop)  to  each  year  of 
the  child's  age,  increasing  the  dose  by  0.06  c.c.  (1  drop)  each  day  until 
the  enuresis  is  controlled  or  the  physiologic  action  of  the  drug  is 
manifest.  A  dose  of  0.6  to  0.72  c.c.  (10  to  12  drops;  is  often  necessary. 
When  a  controlling  dose  is  reached,  it  may  be  held  for  a  week  or  two 
and  then  carefully  decreased,  increasing;  it  afrain  from  time  to  time,  if 
necessary,  to  maintain  the  therapeutic  effect. 

Should  belladonna  fail  to  control  the  enuresis,  a  solution  of  atropine 
and  strychnine  containing  0.13  gm.  (2  grains)  of  atropine  and  0.065  gm. 
(1  grain)  of  strychnine  to  30  c.c.  (1  ounce)  of  water  may  be  prescribed. 
One  drop  of  this  solution  should  be  given  three  times  a  day,  and 
increased  one  drop  a  day  after  the  manner  of  the  administration  of 
the  belladonna.  The  strychnine  is  particularly  valuable  in  diurnal 
incontinence.  Rhus  aromatica,  0.60  c.c.  to  1.25  c.c.  (10  to  20  drops),  is 
often  useful  either  alone  or  combined  with  belladonna.  In  highly  nervous 
children  potassium  bromide  is  sometimes  a  useful  addition. 

The  belladonna  treatment  should  be  continued  over  a  period  of  two 
or  three  months  or  more,  if  necessary.  AVith  the  onset  of  cool  weather 
and  following  dietetic  errors,  or  mild  derangements  of  health,  relapses 
may  occur.      Prompt  renewal  of  the  treatment  will  be  necessary. 

Faradism,  with  the  positive  electrode  in  the  rectum  and  the  negative 
electrode  over  the  pubes,  may  be  tried  in  obstinate  cases,  although  in 
my  experience  it  is  not  often  of  use.  Holt  suggests,  in  old  cases  with 
probable  contracted  bladder,  the  daily  distention  of  the  organ  to  its 
normal  capacity,  with  warm  normal  saline  solution,  and  it  is  worth 
a  trial. 

THE  URINE. 

The  studies,  especially  of  Hok,  Jacobi,  and  INIorse  in  this  country, 
and  of  Baginsky  and  others  in  Europe,  have  revealed  the  previously 
unsuspected  frequency  of  diseases  of  the  urinary  organs  in  infancy 
and  childhood.  AMiile  in  the  diseases  of  adult  life  the  examination  of 
the  urine  is  a  routine  measure  with  all  careful  diagnosticians,  the  real 
and  fancied  difficulties  in  obtaining  a  specimen  of  urine  from  the  infant 
have  deprived  the  physician  of  this  prompt  and  essential  means  of  diag- 
nosis, and  many  cases  of  urinary  disease  have  passed  unrecognized. 
Baginsky  believes  that  many  deaths  from  eclampsia  in  babies  are  really 
caused  by  uremic  convtilsions,  and  it  is  a  common  experience  with  the 
consultant  in  diseases  of  children,  to  find  the  diagnosis  of  a  puzzling 
case  made  plain  by  urinary  analysis.  The  importance  of  urinalysis 
in  cases  of  scarlet  fever,  pneumonia,  influenza,  diphtheria,  gastro- 
enteric catarrh,  etc.,  is  not  appreciated,  and  it  is  unfortunately  too  often 
omitted. 

To  collect  a  specimen  of  urine  from  the  male  infant,  a  small  open- 
mouth  bottle,  with  an  short  neck,  or,  what  is  much  better,  a  rubber 
pouch  or  condom,  may  be  adjusted  over  the  penis  at  a  reasonable  time 
49 


770  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

following  tlic  last  niitturition.  From  the  frmale  infant,  to  obtain  a 
specimen  is  more  troublesome.  A  bottle  or  pouch  may  Ix*  fixed  over 
the  vulva  with  adhesive  plaster  in  the  same  manner  as  in  the  male. 
A  clean,  well-washed  sponge  placed  over  the  vulva,  under  the  diaper, 
is  an  easy  and  often  satisfactory  method;  or,  the  baby  may  Ix'  placed, 
about  the  time  for  urination,  in  its  crib  on  a  rubl)er  sheet,  under  the 
observation  of  the  nurse.  The  application  of  a  cold  cloth  over  the 
region  of  the  bladder  will  often  stimulate  micturition.  Wherever  it  is 
necessary,  there  should  be  no  hesitancy  in  passing  a  catheter.  A  small, 
clean,  soft-rubber  catheter,  passed  with  the  well-known  precautions 
against  infection,  produces  only  insignificant  discomfort  and  is  always 
harmless.  Should  a  twenty-four-hour  specimen  be  required,  this  method 
should  always  he  used. 

The  urine  of  the  newlxjrn  infant  is  small  in  amount,  rarely  more 
than  two  to  eight  ounces  lacing  passed  in  twenty-four  hours.  Complete 
anuria  for  the  first  twelve  to  twenty-four  hours  after  birth  is  not  un- 
common. \\1nle  it  always  should  receive  careful  attention,  it  is  usually 
of  no  significance  and  secretion  is  established  with  the  administration 
of  an  abundance  of  water.  The  first  urine  drawn  with  the  catheter  is 
usually  clear,  with  a  specific  gravity  of  1.006,  small  in  amount  and 
feebly  acid.  On  the  second  or  third  day  it  usually  becomes  cloudy, 
strongly  acid,  highly  colored,  and  with  a  specific  gravity  of  1.010  to 
1.012.  Xa]>kins  are  stained  by  the  uric  acid  crystals.  The  high 
relative  proportion  of  this  constituent  of  the  urine  the  first  few  days  of 
life  produces  the  condition  known  as  uric  acid  infarct  of  the  kidney. 
The  urine  is  strongly  acid.  It  contains  often  a  large  amount  of 
mucus,  which  may  easily  be  mistaken  for  albumin.  This  mucus  is 
probably  the  result  of  irritation  of  the  bladder  from  the  highly  acid 
urine.  Hyaline  casts  are  not  infrecjuently  found  and  epitiielial  elements 
are  abundant.  The  phosphates  do  not  a])pear  until  about  the  fourth 
day.  Subsequently  and  throughout  early  childhood  the  specific  gravity 
of  the  urine  is  low  (1.004  to  1.008),  and  the  coloring  matter  and  other 
salts,  with  the  exception  of  uric  acid,  relatively  small  in  amount.  The 
percentage  of  uric  acid  and  urea  remains  high  during  childhood. 

Albiunin  and  sugar  are  occasionally  present  in  the  urine  of  otherwise 
apparently  healthy  children  during  the  first  month  or  two  of  life.  Sugar 
may  be  present  in  the  urine  of  infants  overfed  with  patented  foods. 

Published  studies  are  not  adequate  to  permit  the  compilation  of  an 
accurate  table  of  the  quantity  in  twenty-four  hours,  the  specific  gravity, 
and  the  percentage  of  the  normal  constituents  of  the  urine  of  the  healthy 
child.  Great  variations  are  found  in  the  results  obtained  by  different 
observers,  and  it  is  difficult  to  account  for  these  differences  unless  it 
Ije  acknowledged  that  the  urine  excretion  in  infants  and  children  is 
subject  to  great  unexplained  physiological  variations.  The  following 
table,  compiled  from  the  studies  of  Holt,  Churchill,  Morse,  and  other 
observers,  gives  an  approximate  average  of  the  amount  in  twenty-four 
hours,  the  specific  gravity,  and  the  urea  content  of  the  urine  during  the 
first  ten  years  of  life: 


DISEASES  OF  THE  BLADDER 


771 


Age. 

Amount  in 

Specific  gravity. 

Urea. 

twenty-four  hours. 

First  week       .       .       .       .    3  to     90  c.c. 

1.010  to  1.004 

0.07  to  0.66 

grams 

Third  month 

200  " 

1.004  "  1.010 

1.4    "  2.3 

Sixth 

250  " 

1.006  "  1.012 

5.0 

Ninth 

300  " 

1.006  "  1.012 

7.0 

First  year 

400  " 

1.006  "  1.012 

11.0 

Second  year 
Third 

450  " 
500  " 

1.006  "  1.012 
1.006  '•  1.012 

12.0 
13.0 

Fourth     " 

550  " 

1.008  "  1.016 

13.5 

Fifth 

600  " 

1.008  •'  1,016 

14.0 

Sixth 

650  " 

1.008  "  1.016 

15.0 

Seventh  " 

700  " 

1.008  "  1.016 

16.0 

Eighth     " 

800  " 

1.008  "  1.016 

18.0 

Ninth       " 

900  " 

1.010  "  1.020 

19.0 

Tenth      " 

1000  " 

1.012  "  1.020 

20.0 

Suppression  of  Urine  in  the  Newborn.— This  condition  occasionally 
results  from  an  acute  renal  congestion,  due  to  the  irritation  of  uric  acid 
infarcts;  it  is  best  described  in  the  following  record:  Male  child,  born 
April  1st,  breech  presentation.  Urinated  freely  at  birth.  Suppression 
of  urine  occurred  on  the  fifth  day  and  continued  six  days.  During  this 
time,  so  far  as  known,  no  urine  was  passed.  Several  warm  baths  were 
given  during  this  period  and  the  infant  may  have  urinated  then.  The 
temperature  ranged  from  normal  to  103°  F.  Four  mild  convulsions 
occurred.  There  was  no  dropsy.  A  specimen  of  urine  obtained  April 
13th  contained  albumin  in  small  quantity,  many  uric  acid  crystals,  red 
blood  cells,  granular  casts,  and  a  few  small,  round  epithelia.  In  a  few 
days  the  urine  cleared.  On  April  24th  it  contained  but  a  faint  trace  of 
albumin  and  only  one  hyaline  cast  was  found.  On  April  16th  profuse 
umbilical  hemorrhage  occurred  and  a  less  severe  intestinal  bleeding. 
Many  purpuric  spots  showed  on  the  body  and  one  very  large  one  on  the 
chest. 

Complete  recovery  followed  the  disappearance  of  the  purpura. 


CYSTITIS. 


Escherich,  Jacobi,  and  other  writers  in  recent  years  have  insisted  on 
the  comparative  frequency  of  cystitis  in  infancy  and  childhood.  In 
infancy  it  most  frequently  occurs  as  a  complication  of  simple  or  specific 
vulvovaginitis  or  enteritis.  Often  the  three  diseases  coexist.  Infec- 
tion in  these  cases  takes  place  by  way  of  the  urethra  or  through  the 
lymph  channels  from  the  intestine.  The  colon  bacillus  is  the  most 
frequent  infecting  organism.  Other  infections  that  have  been  reported 
are  the  bacillus  proteus,  the  bacillus  pyocyaneus,  and  the  various  cocci. 
Tuberculous  infection  is  not  unusual  in  the  general  tuberculosis  of 
childhood.  Infection  may  take  place  from  a  neighboring  abscess,  a^ 
in  the  perineum,  or  from  a  diphtheria  of  the  vulva.  Foreign  bodies, 
traumatism,  calculus,  a  highly  acid  urine,  and  exposure  to  cold  are 
among  the  predisposing  causes  of  infection.  Any  obstruction  to  the 
escape  of  the  urine  predisposes  to  cystitis. 


772  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

Sjmiptomatology. — Cystitis  is  not  infrequently  discovered  in  children 
under  treatment  for  other  diseases.  Careful  incjuiry  in  these  cases 
elicits  a  history  of  mild  vesical  symptoms.  Such  mild  cases  complicating 
other  diseases  usually  promptly  recover  without  special  treatment,  and 
it  is  not  improbable  that  many  of  them  run  their  course  unrecognized. 

In  the  more  pronounced  cases  there  is  acute  pain  in  the  perineum  and 
region  of  the  bladder;  there  is  tenderness  on  pressure  over  the  pubes, 
and  extreme  irritability  of  the  bladder  with  frequent  micturition,  which 
is  accompanied  by  great  pain  and  tenesmus,  especially  toward  the  end 
of  the  act.  In  severe  cases  convulsions  may  occur.  Fever  and  consti- 
tutional symptoms  are  present  in  all  severe  cases. 

The  urine,  which  Is  passed  in  small  quantities,  is  highly  colored, 
cloutly,  and  neutral  or  alkaline  in  reaction.  It  contains  considerable 
mucus  and  a  small  amount  of  albumin,  due  to  pus.  Microsco])ically 
there  are  found  })us,  blood  cells,  proliferating  epithelial  cells,  and  great 
numl)ers  of  bac-teria.  In  hemorrhagic  cystitis  the  urine  is  bright  red 
from  the  contained  blood,  and  often  contains  small  clots.  In  the  later 
stages  a  bad-smelling,  alkaline  urine  with  abundant  deposit  of  phos- 
phates is  characteristic. 

In  ciironic  cystitis  the  same  general  symptoms  are  present,  although 
the  bladder  is  less  irritable  and  the  distress  more  bearable.  With  boys 
itching  or  pain  at  the  end  of  the  penis  is  frequent. 

A  latent  chronic  cystitis  may  result  from  an  acute  attack  and  persist 
unrecognized  for  an  indefinite  period.  In  these  cases  the  colon  bacillus 
may  be  demonstrated  in  the  freshly  voided  urine,  altiiough  on  inspec- 
tion it  may  aj^pear  normal  or  but  slightly  turl)id.  This  latent  form  of 
cystitis  is  most  frequent  in  girls  and  may  be  the  cause  of  an  otherwise 
unaccountable  debility  or  enuresis. 

Diagnosis. — Cvstitis  may  occur  in  conjunction  witli  almost  any  dis- 
ease of  the  genitourinary  tract.  Its  s])ecial  diagnostic  features  are  the 
frequent  and  painful  urination  and  the  com])osition  of  the  urine.  Tiie 
presence  in  the  urine  of  considerable  amounts  of  mucus,  pus,  and 
bladder  e])ithelium,  with  a  relatively  small  amount  of  albumin  in  the 
filtered  urine,  all  speak  for  cystitis,  and  these  (jualities  together  with  the 
absence  of  casts  exclude  nepliritis.  Pyelitis  may  lead  to  vesical  irrita- 
bility. There  is,  however,  in  pyelitis  no  tenderness  of  the  bladder  on 
bimanual  palpation  and  there  is  tenderness  in  the  kidney  region.  The 
contiiuied  fever  of  pyelitis  is  not  present  in  cystitis.  Bacteriological 
examination  for  tiie  definite  recognition  of  the  infecting  agent  should 
be  made  whenever  possil)le. 

Prognosis, — The  marked  tendency  of  the  mild  cases  to  spontaneous 
cure  has  already  been  referred  to.  Under  treatment  the  simple  cases 
recover  in  ten  davs  or  two  weeks.  Gonorrheal  cases  will  be  obstinate. 
The  latent  form  may  run  on  indefinitely  unless  recognized  and  prop- 
erly treated. 

Treatment. — In  mild  cases  rest  in  bed  and  demulcent  drinks  may 
be  all  that  is  required.  In  the  severe  cases  additional  treatment  will 
be  necessary.    Hot  sitz-baths  and  the  application  of  hot-water  fomenta- 


DISEASES  OF  THE  BLADDER  773 

tions  over  the  piibes  and  perineum  are  valuable.  In  the  early  stage 
the  use  of  hyoscyamus  with  alkalies  gives  prompt  relief.  For  severe 
pain  an  opium  suppository  may  be  used  or  syrup  of  Dover's  powder 
administered.  The  diet  should  be  milk  and  the  cereal  gruels.  Bladder 
irrigation  is  difficult  in  children  and  is  not  often  necessary,  ^^^len  pus 
is  abundant  and  the  urine  alkaline,  urinary  antiseptics,  urotropin, 
benzoic  acid,  boric  acid,  or  sandalwood  oil  may  be  given.  When  vesical 
irrigation,  is  necessary,  solution  of  boric  acid,  0.324  to  0.050  gm.  to 
30  CO.  (5  to  10  gr.  to  1  oz.),  or  carbolic  acid,  1:  200,  are  the  most 
useful.  In  every  case  a  careful  search  for  calculus  or  other  removable 
cause  should  be  made. 

Chronic  cystitis  should  be  treated  by  the  persistent  administration  of 
salol  and  urotropin  along  with  a  strict  milk  diet.  Occasional  bacterio- 
logical examination  of  the  urine  will  be  necessary  to  determine  the 
progress  of  the  case  toward  recovery. 


ALBUMINURIA. 

While  late  investigations,  particularly  those  of  IMorner,  have  proven 
that  minute  traces  of  albumin  are  present  in  normal  urine,  the  source 
of  which,  whether  from  the  kidney  or  the  lower  portion  of  the  urinary 
tract,  is  undetermined,  the  presence  of  albumin  in  amount  sufficient 
to  be  detected  by  the  usual  clinical  methods,  unless  due  to  admixture 
below  the  kidneys,  must  be  looked  upon  as  evidence  of  failure  of  the 
renal  epithelium  to  perform  its  normal  function. 

Albuminuria  in  Early  Infancy. — Albuminuria  is  an  almost  constant 
phenomenon  during  the  first  four  or  five  days  after  birth.  In  many 
cases  it  persists  for  two  or  three  weeks  and,  not  infrequently,  for  two 
months.  The  cause  of  this  albuminuria  is  uncertain.  INIany  believe 
it  to  be  a  physiological  condition.  It  has  been  attributed  to  circulatory 
changes  at  birth;  to  postnatal  readjustment  of  metabolism;  to  maternal 
renal  disease;  and  to  lithemia,  so  constant  a  condition  in  the  first  few 
days  of  extrauterine  life. 

This  albuminuria  of  early  infancy  is  transient  and  has  no  prognostic 
significance.  Except  in  early  infancy,  albuminuria  occurs  in  early 
life  under  the  same  conditions  and  has  the  same  significance  as  in  the 
adult. 

Albuminuria  in  Later  Infancy  and  Childhood. — Albuminuria  is  a 
characteristic  symptom  of  acute  and  chronic  parenchymatous  degen- 
eration of  the  kidneys,  of  acute  and  chronic  nephritis,  and  of  amyloid 
and  fatty  degeneration.  It  is  often  present  in  renal  new-growths,  peri- 
nephritis, and  abscess.  It  is  an  associated  phenomenon  in  hematuria 
and  hemoglobinuria  and  in  the  various  pathological  conditions  of  the 
genitourinary  tract,  attended  by  the  formation  of  pus.  A  slight  albumin- 
uria is  often  observed  in  various  constitutional  conditions:  anemia, 
scurvy,  purpura.  It  is  often  present  in  jaundice  and  glycosuria.  It  is 
common  after  epileptic  seizures,  and  has  been  found  after  anesthesia. 


774  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

Aoconliiii^  to  Riuliford,  it  is  frc'(iuciitly  jnvsont  in  early  childluKHl  in 
litlioniia  and  other  toxic  states. 

A  transient  allnnninnria  is  sometimes  due  to  a  movable  kidney,  and 
in  this  condition  it  is  ])ailicularly  noted  after  exercise.  After  a  vigorous 
j)alpati()n  of  a  movable  kidney,  allnnninnria  has  been  ol)S(>rved.  An 
afternoon  albuminuria  is  a  frecjuent  symptom  of  pelvic  calculus. 

In  most  of  these  conditions  the  amount  of  albumin  is  small;  an 
abmidant  albuminuria  is  observed  only  in  grave  acute  or  chronic 
orjranic  disease  of  the  kidnevs. 


FUNCTIONAL  ALBUMINURIA. 

Functional  Albumimu-ia  is  characterized  by  the  appearance  of  albumin 
in  the  urine  in  (juantities  easily  recognized  by  ordinary  clinical  methods, 
continuously  or  during  certain  hours  of  the  day,  and  the  absence  of 
other  symptoms  of  organic  disease  of  the  kidney.  Based  upon  its 
supposed  etiology  or  its  clinical  characters,  writers  have  designated 
the  alVection  neurotic,  dietetic,  ci/clic,  intermittent,  and  paro.rijfimal 
alhuminuria.  l^ider  the  term  cijclic  alhnminiiria  most  of  the  literature, 
which  is  not  abundant,  has  been  written. 

A  study  of  the  literature  of  this  subject  shows  the  utmost  confusion 
in  the  minds  of  observers  as  to  what  constitutes  a  cyclical  albuminuria. 
In  many  of  the  cases  reported,  the  clinical  history  and  the  urinary 
findings  show  conclusively  the  presence  of  organic  renal  disease,  the 
only  excuse  for  terming  the  condition  a  cyclical  albuminuria  being  the 
phenomenon  of  an  albuminuria  absent  or  slight  during  periods  of  rest 
and  more  or  less  abundant  after  physical  exercise.  I  believe  tliat  the 
term  functional  or  cyclic  albuminuria  should  be  confined  strictly  to 
cases  in  which  the  clinical  phenomena  and  urinary  findings  indicative 
of  renal  disease  are  absent. 

Etiology. — The  condition  is  rare  in  infancy  and  early  childliood, 
although  not  infrequently  met  with  in  later  childhood  and  adolescence. 
It  is  most  fre([uent  in  l)oys.  Cold  bathing  and  severe  nuiscular  exertion 
are  among  the  most  frequently  noted  exciting  causes.  Dukes  in  the 
Rugby  School  found  it  in  many  boys  subjected  to  sharp  morning  ex- 
ercise. It  is  occasionally  one  of  the  associate*!  phenomena  of  chronic 
indigestion  and  lithemia.  A  diet  too  rich  in  ])roteids  may  be  the 
cause. 

Pathology. — The  pathology  of  cyclical  albuminuria  is  obscure.  Renal 
irritation  from  lithemia,  vasomotor  disturl)ances,  and  deranged  metab- 
olism, with  the  formation  of  proteids  capable  of  transudation  through 
the  normal  kidneys,  are  among  tlie  most  reasonable  pathological  expla- 
nations of  the  disease.  An  albuminuria  tlu>  result  of  degenerative  or 
inflammatory  changes  in  the  kidney,  however  slight  or  evanescent,  is 
not  a  functional  albuminuria. 

Symptomatology. — Many  patients  are  well  nourished  and  show  no 
symptoms  other  than  the  albuminuria,  which  may  be  discovered  acci- 


DISEASES  OF  THE  BLADDER  775 

dentally.  According  to  Baginsky,  these  patients  are  frequently  pale, 
thin,  and  spiritless.  Some  have  chronic  indigestion,  are  anemic,  and 
suffer  from  various  neuroses. 

The  amount  of  albumin  in  the  urine  is  usually  small,  although  Tyson 
says  that  with  the  heat  test  it  may  amount  to  one-half  the  bulk  of  the 
urine.  The  albumin  may  be  more  or  less  continuously  present,  or  it 
may  be  intermittent.  Typical  cyclical  albuminuria  is  characterized 
by  a  urine  free  from  albumin  in  the  early  morning,  and  containing 
albumin  during  the  hours  from  about  ten  o'clock  in  the  morning  until 
late  in  the  evening.  That  rest  is  the  important  factor  in  checking  the 
excretion  of  albumin  is  shown  by  the  effect  of  a  stay  in  bed.  The  albumin 
disappears,  only  to  reappear  on  the  resumption  of  exercise.  While 
twenty-four  hours  is  the  usual  cycle,  longer  periods  are  recorded. 
Doming  cites  a  case  with  a  Sunday  albuminuria.  An  increase  of  the 
phosphates  is  common,  and  Holt  speaks  of  an  occasional  glycosuria. 
The  urine  is  not  diminished  in  amount,  and  the  specific  gravity  is 
normal  or  high.  The  sediment  frequently  contains  uric  acid,  urates, 
phosphates,  or  oxalates. 

Diagnosis. — An  albuminuria  should  be  declared  functional  only  after 
a  complete  physical  examination  and  repeated  urinary  analyses  have 
failed  to  reveal  the  presence  of  the  clinical  and  laboratory  evidences  of 
organic  renal  disease.  The  presence  of  edema,  cardiac  hypertrophy, 
high  pulse  tension  or  retinal  changes,  with  or  without  other  evidences 
of  impaired  general  health,  means  organic  kidney  disease  regardless  of 
any  peculiarity  in  the  course  of  an  albuminuria.  Deficient  excretion  of 
urea  and  the  presence  in  the  urine  of  hyaline  and  epithelial  casts,  blood, 
pus,  and  renal  epithelium  have  the  same  significance.  Tyson  well  says 
that  "the  most  important  injunction  in  the  recognition  of  this  form 
of  albuminuria  is  a  careful  and  exhaustive  examination  for  casts." 
Even  an  occasional  hyaline  cast  should  be  looked  upon  with  suspicion, 
particularly  in  the  absence  of  any  cause  of  acute  degeneration  of  the 
kidney. 

Prognosis. — The  prognosis  of  a  true  functional  albuminuria  is  favorable. 
The  condition  may  pass  away  in  a  few  weeks  or  persist  for  months. 
Certainty  in  diagnosis,  however,  is  essential  to  a  favorable  prognosis, 
and  every  case  of  albuminuria  should  be  \'iewed  with  suspicion  until  its 
disappearance.  A  chronic  nephritis  in  childhood  is  often  insidious  and 
deceitful.  The  persistence  of  an  albuminuria  beyond  a  few  months  is 
strongly  suspicious  of  organic  disease  of  the  kidney. 

Three  cases  were  observed  by  me  over  a  period  of  ten  to  twenty 
years.  The  first  was  a  medical  student,  and  the  albuminuria  was 
persistent  and  abundant  during  the  whole  of  one  winter.  There  were 
no  other  evidences  of  renal  mischief.  The  patient  was  under  observation 
during  the  winter  of  1882.  Since  leaving  college  he  has  had  no  return 
of  the  trouble.  The  second  was  a  hospital  nurse,  observed  during  the 
years  of  1890  and  1891.  She  had  a  persistent  mild  albuminuria  with 
no  other  evidences  of  renal  disease.  The  albumin  disappeared  after  a 
few  months  and  she  has  remained  perfectly  well  since,  so  far  as  kidney 


77G  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

dise.'use  is  coiiccnied.  The  third  case  was  a  youuii;  man  wlio  had  a 
rather  abundant  alhuminuria  and  was  under  observation  for  a  ])eriod 
of  two  years.  'J'liis  ease  was  earefully  studied.  In  addition  to  tlie 
albuminuria  hyaline  easts  were  oeeasionally  found.  This  eonditiou 
continued,  without  disturbance  of  the  o;tMieral  health,  for  about  five 
years,  then  eharaeteristie  symptoms  of  elironie  nephritis  aj)peared,  and 
the  younfi;  man  died  abou.t  two  years  later. 

j\Iy  experience  agrees  with  that  of  most  authorities,  that  a  persistent 
or  an  intermittent  albuminuria,  while  it  may  be  present  without  any 
other  evidences  of  renal  mischief  and  ultimately  pass  away,  should  be 
looked  u])on  always  with  concern. 

Treatment. — No  drug  with  winch  we  are  familiar  will  influence  the 
excretion  of  albumin  in  the  urine.  'IVeatment  must  be  directed  to  the 
disturbances  of  digestion  and  metabolism  that,  in  all  })robal)ility,  lie  at 
the  foundation  of  the  condition.     Complete  rest  is  often  essential. 

A  carefully  regulated  diet  and  a  healthy  out-of-door  life,  fnv  from 
excessive  muscular  exercise,  are  of  the  most  im])oi-tance.  The  diet 
should  be  liberal  and  carefully  selected.  Excess  of  proteid  food  should  be 
avoided.  Digestive  derangements  and  anemia  should  be  treated.  Iron 
and  arsenic  in  small  doses  are  valuable.  A  cool  morning  bath,  followed 
by  a  good  rubbing,  is  a  valuable  vasomotor  tonic.  Should  the  c(»n(lition 
persist,  a  winter  in  a  mild  climate,  away  from  sudden  changes  in 
temperature  and  high  winds,  would  be  advisable. 


HEMATURIA. 

Blood  in  the  urine  is  a  symptom  of  a  number  of  pathological  con- 
ditions, and  it  may  have  its  origin  from  any  part  of  the  urinary  tract. 
While  usually  symptomatic,  a  number  of  cases  have  been  observed  in 
which  the  hematuria  was  apparently  due  to  an  idiopathic  renal  hemor- 
rhage, a  renal  epistaxis,  as  Durante  has  termed  it.  Senator  designates 
the  condition  "renal  hemophilia." 

Hematuria  in  early  life  more  frequently  has  its  origin  in  the  kidney. 
Traumatisms  of  the  mvthra  and  bladder,  calculus  in  the  bladder,  and, 
rarely,  new-growths  in  the  bladder  may  give  ris(>  to  this  symptom. 

Calculus  in  the  ureter  or  kidney  is  an  occasional  cause.  Hematuria  is 
one  of  the  most  important  symptoms  of  renal  sarcoma,  occurring  in  nearly 
half  the  cases,  and  is  frec|uently  the  first  symptom  noted.  It  is  very  com- 
mon in  active  and  passive  renal  congt\stion  and  nephritis.  The  character- 
istic red  or  smoky  appearance  of  the  urin(>  in  the  early  stages  of  nephritis 
is  due  to  the  presence  of  ])lood.  It  occasionally  is  a  symptom  of  the 
infectious  diseases — typhoid  fever,  virulent  scarlet  fever,  and  influenza. 
Its'  appearance  in  these  fliseases  is  often  indicative  of  the  onset  of  a 
nephritis.  According  to  Thayer,  malaria  never  produces  true  hematuria 
in  children.  Syphilis  is  a  possible  cause.  It  is  a  rare  manifestation  of 
hemophilia  and  hemorrhagic  disease  of  the  newly  bom.  It  has  been 
noted  in  a  nund)er  of  cases  of  infantile  scurvy,  it  being  the  first  and 


DISEASES  OF  THE  KIDNEYS  777 

only  symptom  in  a  number  of  cases  collected  by  the  American  Pediatric 
Society.  I  saw  one  case,  in  consultation,  in  an  infant  six  months  old. 
The  child  had  been  passing  blood  for  four  weeks.  No  other  scurvy 
symptoms  were  present.  A  change  of  diet  promptly  relieved  the  con- 
dition. Morse  also  cites  three  cases  in  which  hematuria  was  the  only 
characteristic  symptom  of  scurvy. 

Diagnosis. — A  hematuria  having  its  source  in  the  kidney  is  often 
intermittent.  The  blood  is  thoroughly  mixed  with  the  urine,  and,  when 
voided,  is  equally  bloody  at  the  beginning  and  at  the  end  of  micturition. 
Blood  casts  of  the  uriniferous  tubules  and  clots  formed  in  tlie  ureters 
are  characteristic  of  renal  hemorrhage.  Pain  is  the  only  distinguishing 
characteristic  of  ureteral  hemorrhage. 

Hemorrhage  from  the  bladder  is  apt  to  be  continuous.  The  first 
urine  voided  is  light  and  contains  little  blood.  Toward  the  end  of 
micturition  the  color  becomes  deeper  and  pure  blood  may  be  passed. 
Pain  and  tenesmus  are  usually  concomitant  symptoms. 

Blood  from  the  prostate  and  urethra  appears  in  the  first  part  of  the 
discharge,  the  urine  voided  last  being  clear  and  free  from  admixture 
with  blood.     Pain  at  the  end  of  micturition  is  frequent. 

The  color  of  urine  containing  ])lood  varies  from  a  smoky  tint  to  a 
dark  red.  The  quantity  of  blood  passed  in  the  urine  may  vary  from 
an  amount  recognizable  only  by  the  microscope  to  a  number  of  ounces. 
The  passage  of  large  quantities  of  blood  is  characteristic  of  the  renal 
hemorrhage  of  sarcoma. 

Treatment. — The  treatment  of  a  hematuria  will  depend  upon  the  cause. 
Rarely  is  it  of  sufficient  abvmdance  to  demand  measures  for  its  arrest. 
Rest  in  bed,  iron,  alum,  and  adrenalin  chloride  are  the  most  efficient 
remedies.      Gelatin- by  the  stomach  and  hypodermically  has  been  used. 


PYELITIS. 

Pyelitis  is  an  inflammation  of  the  pelvis  of  the  kidney.  When  com- 
plicated by  extension  into  the  tubules  of  the  kidney  it  is  termed  pyelo- 
nephritis. When  it  results  in  an  accumulation  of  pus  in  the  pelvis  of 
the  kidney  it  is  termed  pyonephrosis.  The  disease  may  be  primary  or 
secondary,  acute  or  chronic. 

Primary  Pyelitis  is  not  a  common  disease,  although  cases  are  met 
occasionally  in  infant  hospitals  and  in  private  practice  by  physicians 
who  make  it  a  rule  to  examine  the  urine  of  sick  infants.  Many  cases 
undoubtedly  escape  recognition  because  of  neglect  of  urine  analysis. 

Most  of  the  reported  cases  have  occurred  in  female  infants.  The  two 
cases  I  have  seen  were  in  female  infants  under  one  year  of  age. 

The  colon  bacillus  is  the  usual  infecting  organism,  and  it  may  gain 
entrance  to  the  pelvis  of  the  kidney  from  the  intestinal  contents  by  way 
of  the  urethra,  bladder,  and  ureter,  or  by  the  blood  or  lymph  channels. 
It  is  significant  that  many  cases  are  preceded  or  attended  by  mild  intes- 
tinal disorders. 


778  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

Secondary  Pyelitis  is  more  common  than  the  primary  form.  It 
occurs  not  infref|nently  secondary  to  cystitis  from  colon  hacilhis  or 
other  infection,  and  more  rarely  as  a  complication  of  gonorrheal  vagin- 
itis with  or  without  the  intervention  of  a  cystitis.  Irritation  of  the 
pelvis  from  renal  calculi  is  a  frequent  cause.  It  may  result  from  mal- 
formations, renal  tuberculosis,  renal  tumors,  perinephritis  and  peri- 
nephritic  abscesses,  and  pyemia,  and  it  may  occur  as  a  complication 
or  se(|uel  of  several  of  the  acute  infections,  especially  scarlatina,  diph- 
theria, measles,  and  typhoid  fever. 

Symptomatology. — Primary  pyelitis  usually  begins  abruptly.  The 
onset  may  be  marked  by  a  chill,  which  may  be  repeated  at  irregular 
intervals  during  the  course  of  the  disease.  In  the  two  cases  seen  by  me 
chills  were  absent.  The  temperature  rises  rapidly,  often  marking  105°  F. 
or  even  higher,  and  is  accompanied  by  the  usual  symptoms  of  fever. 
The  course  of  the  fever  is  irregular.  The  temperature  may  continue 
high,  with  but  slight  remissions,  or  it  may  show  sharp  remissions  or 
intermissions. 

The  remarkable  feature  of  the  disease  is  the  absence  of  local  symp- 
toms that  would  indicate  that  the  pelvis  of  the  kidney  is  the  seat  of 
trouble.  In  rare  cases  some  evidence  of  pain  antl  tenderness  over  the 
region  of  the  kidney  may  be  elicited.  (Occasionally  a  mild  intestinal 
disturbance,  as  shown  l)y  abnormally  frequent  and  changed  stools, 
may  precede  or  accompany  the  pyelitis.  Unless  the  local  disease  is 
recognized  and  properly  treated  it  may  progress  for  several  weeks  or 
longer,  with  the  wasting,  prostration,  and  other  symptoms  that  result 
from  high  fever. 

Examination  of  the  urine  reveals  the  nature  f)f  the  trouble.  The 
urine  is  scanty,  acid  in  reaction,  and  turbid  from  the  presence  of  pus. 
Albumin  is  present  in  small  amount,  corresponding  to  the  amount  of 
pus. 

The  microscope  shows,  in  addition  to  the  pus,  spindle  and  caudate 
epithelial  cells  from  the  pelvis  of  the  kidney,  a  few  hyaline  casts,  and 
often  crystals  of  uric  acid.  In  recent  or  severe  cases  red  blood  cells. 
The  colon  bacillus  in  pure  culture  may  be  found. 

In  secondary  pyelitis  the  constitutional  symptoms  may  be  obscin^ed 
by  those  of  the  primary  disease  and  the  pyelitis  may  be  recognized  oidy 
by  the  pyuria.  ^Vhen  complicating  cystitis  there  is  frequent  and  often 
painful  micturition.  In  pyelonephritis  a  more  abundant  albuminuria 
is  present,  with  blood,  renal  epithelium  and  hyaline,  granular,  and 
epithelial  casts.  Pyuria,  renal  colic,  hematm'ia,  and  pain  and  tender- 
ness in  the  region  of  the  kidney,  together  with  fever,  are  the  character- 
istics of  pyelitis  complicating  renal  calculi.  Pyelitis  may  be  a  sym])t()ni 
of  renal  tuberculosis.  The  demonstration  of  the  tubercle  bacillus  in 
the  urine  with  the  evidences  of  general  infection  reveal  the  nature  of 
the  primary  disease.  Pyelitis  secondary  to  renal  tumors,  abscess,  and 
perinephritis  is  usually  unilateral  and  shows  characteristic  local  symp- 
toms. A  chronic  pyelitis  may  pursue  an  afebrile  course  or  be  marked 
from  time  to  time  with  periods  of  high  temperature. 


DISEASES  OF  TEE  KIDNEYS  779 

Diagnosis. — Without  urinary  analysis  primary  pyelitis  may  be  con- 
fused with  any  of  the  acute  febrile  diseases.  There  are  usually  no  symp- 
toms that  attract  attention  to  the  urinary  organs,  and  it  is  usual  for 
these  cases  to  be  diagnosticated  typhoid  fever,  malaria,  or  fever  from 
acute  intestinal  toxemia.  Pyelitis  should  be  suspected  in  every  case 
of  unaccountable  fever  in  infancy.  The  diagnosis  can  be  made  positive 
only  by  the  microscopic  examination  of  the  urine.  The  presence  of 
pus  in  an  acid  urine,  together  with  the  chills,  high  irregular  tempera- 
ture, and  perhaps  pain  and  tenderness  in  the  region  of  the  kidney,  are 
characteristic. 

With  a  complicating  cystitis  there  are,  in  addition,  vesical  pain,  fre- 
quent urination,  and  in  the  urine  numbers  of  bladder  epithelial  cells.  The 
possibility  of  tuberculosis  should  be  kept  in  mind  in  every  case  of  pyelitis. 

Prognosis. — Under  proper  treatment  primary  pyelitis  usually  pursues 
a  favorable  course,  terminating  in  complete  recovery  in  from  two  to 
four  weeks.  If  unrecognized  it  may  progress  indefinitely  and  death 
may  result  from  exhaustion  or  some  secondary  infection.  The  prog- 
nosis of  pyelitis  complicating  other  diseases  will  depend  upon  the  nature 
of  the  primary  disease  and  upon  the  treatment. 

Treatment. — At  the  beginning  of  the  attack  the  bowels  should  be 
well  cleared  with  calomel  or  castor  oil.  Subsequently  the  colon  may  be 
flushed  with  normal  saline  solution  every  day  or  so.  The  diet  of  artificially 
fed  infants  should  be  adjusted  to  the  digestive  state.  An  abundance  of 
water  to  thoroughly  flush  the  kidneys  should  be  given  with  moderate 
doses  of  an  alkali  to  neutralize  the  excessive  acidity  of  the  urine.  Citrate 
of  potassium,  0.12  to  0.18  gm.  (2  to  3  gr.)  well  diluted  may  be  given  every 
two  hours  during  the  day.  Urotropin  is  the  most  important  remedy  for 
controlling  the  pyuria.  It  may  be  administered  to  an  infant  one  year 
old  in  the  dose  of  from  0.03  to  0.12  gm.  (V2  to  2  gr.)  every  three  hours. 
The  effect  of  urotropin  must  be  carefully  watched,  as  it  sometimes 
irritates  the  kidneys  and  bladder.  The  efficiency  of  the  remedy  as  a 
urinary  antiseptic  is  impaired  in  a  highly  alkaline  urine,  and  in  some 
cases  with  such  urine  sodium  benzoate  may  be  substituted  for  the 
potassium  citrate  with  advantage. 

The  fever  and  constitutional  symptoms  are  best  controlled  by  hydro- 
therapy. 

In  the  subacute  or  chronic  stage  Jacobi  thinks  well  of  gallic  acid,  0.6 
to  1  gm.  (10  to  15  gr.)  in  the  twenty-four  hours. 


ACUTE  DEGENERATION  OF  THE  KIDNEYS. 

Delafield,  Prudden,  Holt,  and  others  have  clearly  brought  out  the 
clinical  and  pathological  relations  of  Acute  Degeneration  of  the  Kidney. 
By  many  writers  and  clinicians  the  disease  is  confused  with  acute 
nephritis.  Although  recognizing  the  pathology  of  the  condition,  Morse 
and  Kelly  have  named  it  "acute  degenerative  nephritis."  Some  English 
writers  use  the  term  "nephritis"  to  designate  this  condition,  reserving 


780  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

the  name  "Bri{i;ht's  disease"  for  the  diseases  of  the  kidney  characterized 
by  the  ])atli()lo»i;ical  changes  of  inHannnation.  "Febrile  albnininnria" 
is  a  common  synonym.  "For  cHnical  pnrposes  the  recognition  of  the 
fact  that  acute  degeneration  is  the  ordinary  lesion  of  the  infectious 
diseas(\s  is  of  much  ])ractical  importance."     (Delafield.) 

Etiology. — Acute  degeneration  of  the  kidney  is  connnon  in  infancy 
and  childhood.  It  may  complicate  any  of  the  infectious  diseases,  being 
most  fre(juently  seen  in  diphtheria,  scarlet  fever,  typhoid  fever,  and 
pneumonia.  It  is  a  common  condition  in  acute  gastroenteric  tliseases, 
influ<Mi/a  and  malaria,  and  local  pus  infections.  It  is  one  of  the  results 
of  prolonged  high  temp(>rature  from  any  cause.  It  is  found  in  about  all 
the  autopsies  on  children  dying  from  the  acute  infections.  In  addition 
to  the  bacterial  poisons,  it  may  be  caused  by  the  various  toxic  products 
of  erroneous  metabolism.  It  is  thus  found  in  jaundice,  diabetes,  and 
lithemia.  The  ingestion  of  irritating  and  toxic  drugs — such  as  canthar- 
ides,  turpentine,  arsenic,  and  phosphorus — may  cause  the  condition. 

Pathology. — Acute  degeneration  of  the  kidney  is  the  direct  effect  of 
the  action  of  various  toxic  substances  upon  the  renal  e])ithelium  during 
the  elimination  of  these  substances  through  the  kidney.  Cloudy  swelling 
of  the  e])ithelium  of  the  glomeruli  and  tubules,  and  in  the  severe  cases 
fatty  degeneration  and  necrosis,  are  the  distinctive  jiathological  changes. 
Congestion  and  the  exudation  of  serum  may  accompany  these  processes. 
The  kidneys  are  slightly  enlarged,  soft,  and  pale. 

Symptomatology. — Acute  degeneration,  as  it  is  usually  observed  in 
children  during  one  of  the  acute  infections,  runs  its  course  without 
symptoms  additional  to  those  of  the  primary  disease.  The  condition 
can  be  recognized  only  by  urinary  examination. 

The  characters  of  a  febrile  lu-inc  are  present.  The  quantity  is  reduced 
and  the  specific  gravity  high,  1.022  to  1.030.  It  is  turbid  or  clear  and 
high  colored.  Albumin  in  but  a  small  amount  is  present,  although 
in  some  cases,  particularly  in  diphtheria,  the  amount  may  be  large. 
A  few  hyaline  or  granular  casts,  epithelial  cells  and  debris,  and  an 
occasional  pus  cell  are  found  in  the  sediment.  The  urine  returns  to  the 
normal  with  the  end  of  the  primary  infection. 

Diagnosis. — The  presence  of  the  urinary  findings  of  acute  degeneration 
often  leads  to  an  erroneous  diagnosis  of  serious  renal  disease.  While 
acute  nephritis  is  a  not  infrequent  complication  of  the  acute  infections, 
Holt,  Morse,  and  others  have  shown  that  its  frequency  has  been  exagger- 
ated by  many  writers,  who  have  accepted  the  urinary  findings  of  acute 
degeneration  as  indicative  of  the  more  serious  disease. 

Acute  nephritis  is  excluded  by  the  absence  of  the  general  symptoms 
of  this  disease,  by  the  abundant  urine  of  high  specific  gravity,  l)y  the 
small  amount  of  albumin,  and  by  the  absence  of  numerous  hyaline, 
granular,  and  epithelial  casts,  epithelial  debris,  and  blood. 

Again,  acute  degeneration  i-s  a  phenomenon  of  the  early  days  of  an 
acute  infection;  acute  nephritis  is  a  late  complication  or  a  sequel. 

Prognosis. — The  presence  of  acute  degeneration  of  the  kidney  does 
not   materially  influence  the  prognosis  of  an   acute   infection.     With 


DISEASES  OF  THE  KIDNEYS  781 

convalescence  the  condition  usually  disappears.  In  severe  infectious 
diseases  it  may,  however,  interfere  with  renal  excretion  and  contribute 
to  a  fatal  termination.  There  is  no  evidence  to  show  that  a  kidney 
the  seat  of  an  acute  degeneration  is  rendered  more  susceptible  to  acute 
inflammation  later  in  the  course  of  the  primary  infection. 

Treatment. — As  a  rule,  no  treatment  other  than  that  for  the  primary 
disease  is  required.  If  excretion  be  defective,  an  abundance  of  fluid 
and  a  diet  and  medication  selected  with  the  view  of  producing  the 
least  possible  irritation  of  the  kidneys  are  advisable.  In  gastroenteric 
diseases  the  relief  of  the  irritation  by  proper  diet,  etc.,  wifl  frequently 
end  the  symptoms  of  the  degeneration. 


ACUTE  NEPHRITIS. 

This  condition  has  been  also  described  as  acute  exudative  nephritis, 
productive  nephritis,  diffuse  nephritis,  glomerulonephritis,  parenchy- 
matous nephritis,  catarrhal  nephritis,  and  acute  Bright's  disease. 

Etiology. — Acute  nephritis  may  be  primary  or  secondary.  Of  the 
two  forms,  the  secondary  is  by  far  the  more  frequent.  From  the  liter- 
ature and  his  own  experience,  Holt  collected  twenty-four  cases  of  primary 
nephritis  in  infants  under  the  age  of  two  years.  I  have  observed  but 
one,  a  fatal  case.  In  older  children,  also,  the  primary  form  is  rare.  I 
have  seen  three  cases  in  consultation  in  the  last  two  years,  all  of  them 
fatal.  Exposure  to  cold  and  wet  is  the  probable  cause  of  the  primary 
form. 

The  most  frequent  cause  of  secondary  nephritis  is  one  of  the  acute 
infections,  especially  scarlet  fever  and  diphtheria.  While  more  frequent 
in  the  severe  cases  of  these  diseases,  it  may  occur  even  in  the  mildest 
form  and  regardless  of  every  precaution  for  its  prevention.  It  is  an 
interesting  fact  that  nephritis  is  usually  a  late  complication  or  a  sequel 
of  scarlatina. 

While  the  disease  is  due  to  the  direct  toxic  action  of  the  scarlatinal 
virus  on  the  kidney,  it  would  thus  appear  that  the  secondary  strepto- 
coccus infection  may  also  play  an  important  role. 

M<jre  rarely  it  complicates  measles,  epidemic  parotitis,  varicefla, 
variola,  typhoid  fever,  pneumonia,  and  meningitis.  The  literature  of 
the  last  few  years  contains  numerous  reports  of  cases  complicating 
influenza,  malaria  and  tonsillitis.  Considering  the  great  prevalence  of 
influenza  during  the  last  fifteen  years  and  the  few  cases  of  nephritis 
reported,  it  must  be  looked  upon  as  a  rare  complication.  Personally 
I  have  observed  but  one  case.  Local  and  systemic  pus  infections,  erysip- 
elas, dysentery,  acute  rheumatism,  impetigo,  and  pustular  eczema  are 
occasional  causes.  As  in  acute  degeneration,  leucomains  and  chemical 
poisons  may  also  produce  nephritis.  Infants  and  children  of  any  age 
may  have  nephritis,  although  it  is  more  common  in  the  middle  period 
of  childhood.  Boys,  from  their  more  careless  lives,  are  more  frequently 
affected, 


782  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

Pathology  and  Pathological  Anatomy. — Tlic  (Ictcniiiiiatioii  of  nephritis 
as  a  t'oni])lication  of  one  of  tho  infcrtions  is  usually  the  direct  result 
of  the  action  of  a  toxin,  elaborated  by  the  provoking  micro-organism, 
during  the  process  of  its  elimination  by  the  kidney.  In  some  of  the 
svstemic  infections,  particularly  typhoid  and  septicemia,  in  which  the 
organisms  are  in  the  circulating  blootl,the  bacteria  themselves  may  be 
the  pathogenic  factors, 

Tlie  kidneys  are  enlarged,  in  the  severe  cases  sometimes  to  twice 
the  natural  size.  They  are  soft  and  edematous.  The  tense  capsule  is 
not  adherent.  The  smooth  surface  of  the  kidney  is  dark  reddish-brown, 
or  it  may  be  pale  or  mottled  and  streaked  with  (lilatcd  vessels  (Fig.  102). 

Fig. 162 


Acute  parenchymatous  nephritis:  A,  tubules  showing  cloudy  swelling;  B,  congested  Mal- 
pighian  tult;  C,  tubules  with  desquamated  epithelium;  D,  Bowman's  capsule  infiltrated  with 
leukocytes. 

On  section,  the  kidney  shows  a  swollen  and  edematous  cortex,  corre- 
sponding in  color  to  the  surface.  The  normal  striations  are  obscured. 
The  whole  pyramid  or  its  boundary  only  is  dark  and  congested. 

The  inHannnatory  lesions  involve  all  the  structures  of  the  kidney. 
When  the  process  is  most  intense  in  the  tubules  it  is  designated  tubular 
nephritis;  in  the  glomeruli,  glomerular  or  r/lomernloncphritis;  in  the 
interstitial  tissue,  productive  or  interstitial  nephritis. 

Delafield  recognizes  an  acute  exudative  and  an  acute  productive 
nephritic 

Symptomatology. — The  onset  of  primary  nephritis  is  often  abrupt, 
the  disease  beginning  with  fever,  headache,  vomiting,  restlessness, 
muscular  twitchings,  and,  rarely,  convulsions.  While  not  usually  an 
early  symptom,  dropsy  occasionally  first  directs  the  attention  of  the 


DISEASES  OF  THE  KIDNEYS 


783 


physician  to  the  kidneys.  In  many  cases  the  beginning  is  insidious, 
without  marked  renal  symptoms,  and  will  be  detected  only  by  the 
physician  who  always  examines  the  urine  of  sick  children.  The  temper- 
ature is  irregular  in  t\-pe  and  not,  as  a  rule,  high.  Fever  may  be  absent 
during  the  first  few  days.  In  infants,  however,  a  high  temperature 
is  often  seen.    Diarrhea  has  been  noted  in  quite  a  number  of  cases. 

In  addition  to  the  nervous  s^Tnptoms  above  noted,  severe  cases  with 
uremia  show  dulness  and  apathy,  sometimes  approaching  coma.  Holt 
states  that  anemia  was  a  prominent  symptom  in  his  cases,  and  in  several 
instances  suggested  the  diagnosis. 


Fig. 163 


Urinary  sediment  in  acute  nephritis ;  hiyaline,  granular,  and  epittielial  casts 


The  urine  may  not  be  greatly  decreased  in  amount,  particularly  in 
the  beginning  of  the  disease.  Later  it  is  often  scant,  and  not  infrequently 
suppressed.  This  symptom  varies  greatly  in  different  cases  and  at 
different  times  in  the  course  of  an  individual  case.  It  is  high  colored 
and  turbid,  often  red  or  smoky  from  the  presence  of  blood.  The  specific 
gravity  is  high  with  scanty  and  low  with  abtmdant  urine.  Albumin  is 
always  present  and  in  varying  amounts,  even  enough  to  coagulate  solid 


784  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

oil  boiling'.    The  ainoiint  may  vary  greatly  from  day  to  day,  regardless  of 
other  symptoms. 

Casts — hyaline,  granular,  epithelial— are  always  present,  usually 
together  with  epithelial  cells,  debris,  leukocytes,  and  blood  cells  (Fig.  163). 
In  some  cases  there  may  lu'  only  an  occasional  granular  or  hyaline 
cast,  and  in  others  many  of  all  varieties.  Dropsy  may  be  slight  or 
marked.  In  one  of  my  cases,  an  infant  whose  history  follows,  dropsy 
was  very  severe  during  the  whole  course  of  the  disease. 

The  patient  was  a  girl,  aged  twenty-three  months.  Prior  to  the 
attack  she  was  a  well  child;  no  history  of  cold  or  any  infection.  On 
May  1st  on  awaking  from  her  afternoon  sleep  her  nurse  noticed  a 
puffiness  of  the  face.  Otherwise  she  was  apj^arently  well.  She  passed 
a  restless  night.  The  nexi;  day  she  was  fretful,  with  no  appetite,  and 
in  the  evening  she  vomited.  Another  fretful  night.  She  complained 
much  of  thirst,  and  vomited  again  on  the  morning  of  the  third  day. 
The  edema  was  confined  to  the  face  below  the  eyes. 

The  child  was  seen  by  the  attending  physician  on  the  evening  of 
INIay  3d.  The  puffy  face  and  vomiting  led  to  an  immediate  examination 
of  the  urine.  The  nurse  thought  it  somewhat  diminished  from  the 
normal.  A  small  sj^ecimen  was  obtained  and  found  to  contain  44  per 
cent,  of  albumin  by  bulk  after  precipitation,  and  great  numbers  of 
hyaline  easts.  The  child's  temperature  was  99.2°  F. ;  pulse  120.  On 
the  following  morning  the  child  was  much  better,  and  for  five  days  she 
did  not  ap])ear  very  ill.  She  was  bright  anfl  playful.  A  slight  edema 
then  a])pearc(l  in  the  feet  and  legs,  wliich  steadily  increased.  During 
this  time  the  temperature  did  not  rise  above  99.2°  F.,  and  there  was  a  fair 
amount  of  urine  excreted.  May  7th  analysis  showed  the  following: 
specific  gravity,  1.028;  reaction,  acid;  color,  normal;  albumin,  14  per 
cent,  by  l)ulk.  Sediment:  numerous  hyaline  and  a  few  granular  casts; 
one  fatty  cast;  a  few  large  and  small  round  epithelia,  and  a  few  pus 
and  red  blood  cells. 

May  10th  a  twenty-four-hour  specimen  showed  the  following:  quantity, 
100  c.c;  s])ecific  gravity,  1.044;  total  solids,  10.25  gm.;  color,  normal, 
cloudy;  all)umin,  0.085  per  cent,  by  weight;  urea,  4.4  per  cent.  Micro- 
scope: many  hyaline  and  a  few  granular  casts;  many  pus  cells  and 
small,  round  epithelia,  some  showing  fatty  degeneration. 

From  INIay  10th  to  May  16th  there  was  a  steady  increase  in  the 
edema.  Except  a  lower  specific  gravity,  the  urine  did  not  materially 
change  in  character.  May  18th,  symptoms  were  all  increased  in  severity. 
Temperature,  102°  to  103°  F. ;  pulse,  150  to  160.  Great  general  anasarca 
and  ascites.  Although  the  urine  excretion  was  maintained,  the  child 
steadily  grew  worse  and  died  May  20th,  rather  suddenly,  of  cardiac 
failure. 

The  following  is  a  case  in  point:  Child  was  born  October  14th. 
Apparently  healthy  female,  weighing  seven  pounds  two  ounces.  Urine 
passed  shortly  after  birth.  Suppression  on  third  day,  with  evening 
temperature  of  103°  F.  Specimen  of  urine  obtained  on  fifth  day  con- 
tained   albumin    in    small    quantity,   uric    acid    crystals,   blood    cells, 


DISEASES  OF  THE  KIDNEYS 


785 


and  hyaline  and  granular  casts.  This  was  the  only  analysis  made. 
During  the  course  of  the  disease  urine  was  passed  only  occasionally 
and  in  very  small  quantity.  Fever  of  a  remittent  type  continued,  vary- 
ing from  99°  to  104°  F.  The  child  was  drowsy,  cried  feebly  at  times,  and 
showed  muscular  twitching.  No  dropsy.  She  gradually  sank,  and  died 
on  the  sixteenth  day.  Autopsy  revealed  an  acute  nephritis  of  the 
hemorrhagic  type  (Fig.  164). 


Fig.  164 


■.p:\ 


^:,^-;. 


Acute  hemorrhagic  nephritis  in  the  newly  born. 


The  affection  lasts  from  two  to  four  weeks.  In  infants  acute. primary 
nephritis  runs  a  grave  course. 

Death  occurs  from  acute  uremia  or  from  some  one  of  the  complications 
to  which  these  patients  are  subject.  Edema  of  the  lungs  or  glottis, 
effusion  into  the  serous  cavities,  pericarditis,  endocarditis,  pleurisy, 
pneumonia,  and  meningitis  are  most  frequently  noted. 

The  symptoms  of  nephritis  secondary  to  one  of  the  acute  infections 
do  not  differ  materially  from  those  of  the  primary  form.  When  it 
occurs  during  the  height  of  the  febrile  process,  the  general  symptoms 
are  concealed  by  those  of  the  primary  disease,  and  with  neglect  of  the 
examination  of  the  urine  it  may  escape  recognition  until  suppression 
or  a  uremic  accident  rudely  reminds  the  physician  of  his  carelessness. 
Coming  on  when  convalescence  has  begun,  it  is  more  readily  recognized. 
There  is  a  check  in  the  progress  of  recovery.  Fever  returns,  and  with 
it  vomiting,  headache,  prostration,  and  a  scant,  smoky  urine.  The 
temperature  ranges  from  100°  to  102°  F.,  rarely  in  severe  cases  reaching 
104°  or  105°  F.  Dropsy  is  usually  present.  Effusion  into  the  serous 
cavities  is  not  infrequent.     Anemia  is  marked. 

The  urine  is  diminished  in  quantity,  often  suppressed.  The  specific 
gravity  is  low  and  the  urea  diminished.  The  color  is  dark  red  or  smoky 
50 


786  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

from  the  pivsciuo  of  rnilirocvtos  or  hemoglobin.  Albumin  is  always 
])rcscnt,  usually  in  laro;o  amount.  The  sediment  contains  casts  in  (jjreat 
numbers;  e])itlielial,  granular,  hyaline,  and  blood  easts  are  found  during 
the  early  stage  of  the  disease.  Later  the  e})ithelial  and  blood  casts 
disa])pear.  Renal  epithelium,  red  blood  cells,  and  leukocytes  are 
friMjuent. 

The  duration  of  a  secondary  nephritis  is  from  two  to  four  weeks. 
Approaching  convalescence  is  marked  by  a  decline  in  the  constitutional 
symptoms  and  an  increase  in  the  excretion  of  urine,  with  a  diminution 
in  the  albumin  and  the  number  and  variety  of  the  casts.  Traet>s  of 
albumin  and  a  few  hyaline  casts  may  persist  in  the  urine  for  a  number 
of  weeks.  In  children,  left  ventricle  hypertrophy  and  accentuation  of 
the  aortic  second  sound  develop  early. 

Diagnosis. — ^The  diagnosis  of  acute  nephritis  rests  upon  the  findings 
of  urinary  analysis.  Chemical  and  microscopic  examination  of  the 
urine  should  be  made  a  routhie  measure  in  the  diseases  of  children,  as 
it  is  hi  the  diseases  of  aduU  life.  With  proper  examination  of  the  urine, 
acute  nephrhis  can  be  confused  only  with  acute  degeneration  of  the 
kidneys. 

The  distinguishi-ig  features  of  the  two  conditions  are: 

AcuTK  Nephritis.  Acute  Deceneration. 

May  be  primary  or  secondary.  Always   secondary    to   an    acute    infection   or 

Intoxication. 
Urine  diminished,  scant,  or  suppressed.  Urine  diminislicd  but  sligiitly,  or  not  at  all. 

Specific  gravity  normal,  usually  decreased.  Specific  gravity  normal  or  high. 

Urea  markedly  decreased.  Urea  normal 

Albumin  always  present  in  considerable  amount.        Albumin  present  in  small  amount,  usually  only 

a  trace. 
Casts  of  all   varieties,    blood,    pus,    abundant       Only  a  few  hyaline  casts  present ;  granular  casts 
epithelial  cells,  and  epithelial  debris.  rare  ;  no  blood  or  pus;  only  occasional  renal 

epithelium  or  epithelial  debris. 

Prognosis. — Primary  acute  nephritis  is  a  serious  disease.  Infants 
and  young  children  frec|uently  die.  Older  children  less  frequently 
succumb.  Of  the  twenty-four  cases  in  infants  of  Holt,  sixteen  died. 
Of  the  four  eases  seen  by  me  during  the  last  two  years,  all  died.  It 
should  be  remembered,  however,  that  on  account  of  the  common  neglect 
of  urinary  examination  in  infants  many  mild  cases  may  run  their  course 
unrecognized.  The  inflammation  is  usually  of  the  exudative  type  and 
recovery,  when  it  occurs,  is  complete. 

The  immediate  danger  to  life  in  secondary  acute  nephritis  is  not  so 
great  as  in  the  primary  form,  death  rarely  resulting  from  the  renal 
disease  hi  the  acute  stage.  As  Delafield  and  others  have  shown, 
secondary  ne])hritis,  particularly  when  c<)m])licatiiig  scarlatina,  is  often 
of  the  productive  type,  and  the  beginning  of  the  chronic  form  of  the 
disease.  A  guarded  prognosis  should  be  given  in  scarlatinal  nephritis, 
even  when  a})parent  recovery  has  taken  place,  and  the  child  should  be 
kept  under  medical  observation  for  several  months  or  years. 

Suppression  of  the  urine,  .severe  nervous  .sym])t<)ms,  persistent  vomit- 
ing, a  severe  anasarca,  effusion  into  the  serous  cavities  are  unfavorable 
phenomena.     The  amount  of  albumin  in  the  urine  has  no  prognostic 


DISEASES  OF  THE  KIDNEYS  787 

significance.  The  amount  of  urine  and  the  character  of  the  sediment 
are  better  guides. 

Treatment. — Much  may  be  done  during  the  course  of  the  acute  infec- 
tious diseases  to  prevent  the  onset  of  comphcating  nephritis.  A  simple 
fluid  diet  consisting  largely  of  milk,  with  the  avoidance  of  meat,  should 
be  kept  up  v^ell  into  the  convalescent  stage.  Bearing  in  mind  the  etio- 
logical relation  of  the  micro-organisms  and  toxins  of  acute  infections  to 
nephritis,  measures  directed  to  the  maintenance  of,  abundant  elimina- 
tion are  to  be  continued  throughout  the  course  of  these  diseases.  Con- 
stipation should  be  carefully  combated.  Free  elimination  by  the 
kidneys  should  be  ensured  by  an  abundance  of  fluid,  often  best  admin- 
istered in  the  form  of  alkaline  carbonated  waters,  lemonade  or  other 
mild,  agreeable  beverages.  The  daily  bath,  warm  or  cool,  is  a  grateful 
measure  for  the  stimulation  of  metabolism  and  elimination.  Every 
effort  should  be  made  to  limit  secondary  streptococcus  and  other  infec- 
tions. The  throat  and  nasopharynx  are  the  chief  portals  of  entry  of 
these  secondary  infections;  hence  the  importance  of  throat  and  naso- 
pharyngeal cleanliness.  The  daily  irrigation  of  the  nose  and  throat 
with  a  mild  alkaline  and  antiseptic  solution  is  advisable  in  every  case 
of  acute  infectious  disease,  however  mild;  in  scarlatina  and  diphtheria 
it  is  essential. 

With  the  onset  of  an  acute  nephritis  the  child  should  be  given  abso- 
lute rest  in  bed;  even  in  the  mildest  cases  this  should  be  done  and, 
except  when  convalescence  is  protracted,  the  patient  should  be  kept  at 
rest  until  the  albuminuria  ceases.  When  permitted  to  be  up,  the 
patient  should  be  carefully  guarded  against  excess,  and  the  effect  of 
exercise  upon  renal  excretion  noted  by  repeated  urinary  analyses.  From 
the  onset  of  the  disease  the  total  quantity  of  urine  eliminated  in 
each  twenty-four  hours  and  its  specific  gravity  should  be  noted  and 
recorded. 

A  daily  warm  bath  stimulates  diaphoresis  and  diuresis,  and  is  to  be 
recommended. 

A  strict  regulation  of  the  diet  with  the  careful  adjustment  of  the 
proteid  content  of  the  food  to  the  demands  of  nutrition  and  to  the  func- 
tional activity  of  the  diseased  kidneys  and  the  avoidance  of  substances 
difiicult  to  excrete  is  essential. 

von  Noorden  and  Chittenden  have  shown  that  a  man  weighing  154 
pounds  (70  kilos)  will  maintain  his  nitrogenous  equilibrium  under  con- 
ditions of  moderate  activity  with  a  diet  containing  from  50  to  60  grams 
of  proteid.  From  this  it  may  be  estimated  that  a  child  aged  four  years 
may  maintain  a  fair  nutrition  during  the  short  period  of  an  acute  ill- 
ness with  food  containing  25  grams  of  proteid;  a  child  of  eight  years 
with  30  grams;  and  a  child  of  twelve  years  with  35  grams.  The  total 
caloric  need  of  these  children  under  such  circumstances  will  not  exceed 
1000  calories  at  four  years;  1200  calories  at  eight  years;  and  1400 
calories  at  twelve  years. 

The  kidney  excretes  with  difficulty  urea,  creatinin,  phosphates  and 
water.    Proteid  food   yields  urea;   creatinin  is  a   large  constituent  of 


788  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

meat  extracts  and  broths;  phosphoric  acid  is  contained  in  large  amounts 
in  meats,  yolks  of  eggs,  milk  and  many  vegetables. 

With  these  data  it  is  not  difficult  to  construct  a  dietary  suitable  to 
an  acute  nephritis. 

Milk  has  long  been  considered  the  ideal  food  in  nephritis.  It  should 
not  be  the  sole  food,  but  may  be  the  chief  proteid-containing  article  of 
diet.  Each  100  c.c.  of  milk  contain  4  grams  of  proteid.  (500  c.c. 
(20  oz.)  will  supply  the  proteid  need  of  a  child  of  four  years;  750  c.c. 
(25  oz.)  of  a  child'of  eight  years;  and  900  c.c.  (30  oz.)  of  a  child  of 
twelve  years.  The  caloric  yield,  however,  of  these  quantities  of  milk 
is  not  sufficient.  Each  100  c.c.  of  milk  supply  approxiniates  but 
70  calories,  making  the  total  yield  of  the  quantity  of  milk  which 
contains  the  necessary  proteid,  about  one-half  of  that  necessary  for 
nutrition. 

The  deficiency  of  calories  may  be  made  up  by  the  use  of  foods  rich 
in  carbohydrates  and  fat  and  containing  a  small  per  cent,  of  proteid, 
such  as  cream,  butter,  sugar  and  the  cereal  products.  These  foods  may 
su])plement  the  milk  in  the  dietary.  For  example,  16  oz.  milk,  4  oz. 
cream,  1  oz."  butter,  2  oz.  of  bread  and  1  oz.  of  sugar  contain  aj)proxi- 
mately  the  25  grams  of  proteid,  and  will  yield  approximately  the  1000 
calories  necessary  for  the  daily  nutrition  of  a  child  aged  four  years. 
During  the  early  stage  of  the  disease  milk,  diluted  cream  and  the  cereal 
gruels  should  constitute  the  diet — later  the  solids  may  be  added.  Return 
to  a  usual  meat  containing  diet  should  not  be  made  until  convalescence 
is  well  along.  Additional  articles  of  food  should  be  given  carefully 
and  the  effect  on  renal  excretion  noted.  An  increase  or  a  return  of  the 
albuminuria  will  caution  still  further  delay. 

A  brisk  calomel  purge  should  begin  the  treatment  of  nephritis,  and 
subsequently  throughout  the  disease  a  thorough  evacuation  of  the 
bowels  should  be  ensured  daily  by  the  administration,  if  necessary,  of 
an  efficient  laxative.  Children  usually  take,  without  trouble,  citrate  of 
magnesia,  compound  licorice  or  jalap  powder,  and  sometimes  the  sul- 
phated  mineral  waters. 

With  this  hygienic  and  dietetic  treatment  guarding  the  inflamed  kidney 
from  irritation  and  excessive  work,  acute  nephritis  usually  terminates  in 
recovery. 

In  severe  cases  suppression  of  the  urine  with  its  sequels,  dropsy  and 
uremia,  will  demand  active  treatment.  In  the  early  stage  the  kidneys 
are  engorged  with  blood  and  their  function  is  arrested.  They  are 
practically  impervious  to  water. 

To  relieve  engorgement  and  aid  in  the  restoration  of  secretion, 
counterirritation  may  l)e  made  over  the  kidney  with  dry  cups,  and  this 
followed  by  the  application  of  a  hot  compress  or  poultice. 

When  engorged  the  kidneys  eliminate  water  with  difficulty,  conse- 
quently the  fluid  should  be  restricted  to  the  amount  absolutely  neces- 
sary to  maintain  nutrition  and  should  not  exceed  from  1000  c.c.  to  1200 
c.c,  depending  upon  the  age  of  the  child.  Most  of  this  will  be  given 
in  the  milk  and  cream  of  the  food. 


DISEASES  OF  THE  KIDNEYS  789 

The  bowels  and  skin  should  be  called  upon  to  relieve  the  kidneys  of 
the  work  of  eHmination.  Free  catharsis  is  always  indicated;  diaphoresis 
chiefly  when  dropsy  is  present.  The  skin  can  only  eliminate  water; 
the  excretory  solids  must  be  eliminated  by  the  bowels.  The  hot  pack 
is  the  most  reliable  diaphoretic.  In  an  emergency  pilocarpin  may  be 
given. 

Rectal  irrigation  with  normal  saline  solution  at  a  temperature  of 
106°  to  108°  F.,  with  a  double  tube,  is  efficient  in  relieving  engorgement 
and  restoring  secretion. 

For  uremic  symptoms  with  high  pulse  tension,  nitroglycerin  0.00021 
gm.  to  0.00032  gm.  (g^  to  yto"  g^'-)  every  hour  for  four  or  five  doses 
is  useful.  Chloral,  by  rectum  0.065  gm.  to  0.13  gm.  (1  to  2  gr.)  for 
each  year  and  repeated  in  from  two  to  three  hours,  should  be  given 
when  nervous  symptoms  are  present.  For  convulsions,  chloral,  as  above, 
or  morphine  hypodermically  may  be  given.  Chloroform  carefully 
administered  hastens  relaxation  and  gives  the  more  slowly  acting  seda- 
tives time  to  produce  their  effects.  In  grave  cases  the  abstraction  of 
from  90  c.c.  to  150  c.c.  (3  to  5oz.)  of  blood,  with  the  introduction  of 
normal  saline  solution  by  hypodermoclysis  or  enteroclysis,  may  save 
life. 

The  onset  of  anemia  is  rapid,  and  early  in  convalescence  demands 
iron.  Recovery  in  severe  cases  is  slow  and  requires  the  most  careful 
guidance.  Continuation  of  the  dieting  and  the  hygienic  precautions 
above  laid  out  may  be  necessary  for  several  weeks  or  more.  Whenever 
possible,  the  winter  in  a  dry,  warm  climate  is  advisable  for  two  or  three 
years.  The  possibility  of  the  insidious  development  of  a  chronic  nephritis 
should  never  be  forgotten. 


CHRONIC  NEPHRITIS. 

Two  forms  of  chronic  nephritis  have  received  general  recognition: 
1.  Chronic  Parenchymatous  or  Diffuse  Nephritis.  2.  Chronic  Inter- 
stitial Nephritis. 

In  both  of  these  forms  of  nephritis  there  are  changes  in  the  epithelium, 
the  glomeruli,  and  the  stroma.  The  predominance  of  the  changes  in 
one  or  the  other  of  these  elements  of  the  kidney  does  not  influence  the 
clinical  symptoms.  Delafield  holds  that  the  essential  difference  in  the 
pathological  processes,  the  difference  that  determines  the  clinical  course 
of  the  disease,  is  the  presence  or  the  absence  of  exudation.  "In  all 
these  kidneys  two  changes  are  constant — productive  inflammation  of 
the  glomeruli  and  stroma  and  desquamation  of  the  renal  epithelium. 
The  only  real  difference  between  the  kidneys  is  whether,  besides  the 
growth  of  new  tissue  and  desquamation  of  the  renal  epithelium,  there 
is  or  is  not  an  exudation  of  serum  from  the  bloodvessels  of  the  kidneys." 
So  that  Delafield  terms  the  two  pathological  varieties  of  chronic  nephritis 
"  chronic  productive  nephritis  with  exudation  "  and  "  chronic  productive 
nephritis  without  exudation." 


790 


DISEASES  OF  THE  (lENITOURINARY  SYSTEM 


Chronic  Parenchymatous  Nephritis.  Etiology. — Tliis  form  of  chronic 
nephritis  is  the  one  more  frecjuentl}'  ol)serve(l  in  childhood.  Compared 
with  adult  life,  it  is  rare  in  childhood.  It  is  most  frecjucntly  seen  after 
the  age  of  five  years,  while  in  early  childhood  and  in  infancy  it  is  very 
rare.  As  a  rule,  it  occurs  in  children  as  a  sequel  to  acute  nephritis  of 
the  productive  type,  occurring  as  a  complication  of  scarlatina.  The 
history  of  these  cases  often  shows  a  sequence  of  several  of  the  acute* 
infections  occurring  during  the  two  or  three  years  preceding  the  onset 
of  the  nephritis.  Syphilis,  tuberculosis,  chronic  endocarditis  or  chronic 
sup])urations  are  occasional  etiological  antecedents.  Rarely  a  case  is 
met  that  is  chronic  from  the  onset  and  can  be  traced  to  no  adec^uate 
cause. 

Fig. 165 


Chronic  cliffuse  imreiichymalous  nephritis  :     A,  young  eonnective  tissue;   B,  dilated  tubule  with 
llattened  epitlielium ;   C,  tubule  with  partially  desquamated  epithelium. 


Pathology. — The  gross  and  microscopic  patliological  anatomy  of 
the  kidney  in  the  chronic  nc])hritis  of  childhood  is  tlu*  same  as  seen  in 
the  adult.  The  large  white  kidney  is  most  frc(jU(Mitly  seen  and  it  is 
sometimes  enormously  enlarged.  Ashby  and  Wright  cite  a  case,  a 
girl  of  twelve  years,  in  whom  the  two  kidneys  together  weighed  twenty- 
two  and  three-quarter  ounces,  and  the  left  kidney  measured  six  inches 
in  length.  Tn  cases  in  which  the  fatal  termination  is  long  delayed  the 
small  white  kidney  sometimes  is  seen  (Fig.  165). 

Symptomatology. — An  acute  nephritis  may  pass  on  to  the  chronic 
form  without  an  intermission  in  the  symptoms,  or,  after  an  interval 
during  which  the  patient  appears  in  good  health,  persistent  renal 
symptoms  develop.     In  a  certain  number  of  cases  twf)  or  more  attacks 


DISEASES  OF  THE  KIDNEYS  791 

of  what  appears  to  be  acute  nephritis  precede  the  fixation  of  the  chronic 
disease.  In  such  cases  it  is  probable  that  a  mild  productive  inflam- 
mation without  exudation  is  continuous,  and  that  the  so-called  acute 
attacks  are  exacerbations  in  the  symptoms  that  mark  extensions  or 
renewals  of  the  exudative  process.  Occasionally  no  history  of  an  acute 
nephritis  can  be  obtained. 

Dropsy  is  a  characteristic  symptom  of  chronic  parenchymatous 
nephritis.  It  may  appear  as  a  localized  or  a  general  edema  or  as  an 
effusion  into  one  of  the  serous  cavities.  Anemia  is  another  marked 
symptom  and  with  the  dropsy  give  the  characteristic  puffy,  pasty  skin 
of  chronic  Bright 's  disease. 

Digestive  disturbances  are  prominent — anorexia,  indigestion,  and 
attacks  of  vomiting  or  diarrhea.  Headache,  insomnia,  dyspnea,  and 
other  uremic  phenomena  appear  from  time  to  time.  Persistent  debility 
with  anemia  are  sometimes  the  only  symptoms  to  direct  the  attention 
to  the  kidneys.  Cardiac  hypertrophy  is  present  in  all  cases  that  have 
continvied  for  any  length  of  time.  In  children,  retinal  changes  are  not 
common. 

The  urine  is  often  normal  in  amount,  often  diminished,  sometimes 
increased.  The  specific  gravity  is  usually  low  and  the  urea  excretion 
diminished.  Albumin  is  always  present,  usually  in  moderate  or  large 
amount,  often  0.5  per  cent,  or  more  by  weight.  During  the  intervals 
between  exacerbations  the  quantity,  specific  gravity,  and  urinary  solids 
may  be  but  slightly  or  not  at  all  below  the  normal;  at  these  times 
only  a  trace  of  albumin  may  be  present. 

The  urine  is  often  cloudy  and  contains  an  abundant  sediment.  The 
microscope  shows  many  epithelial  cells  and  much  epithelial  debris  with 
hyaline,  granular,  and  epithelial  casts.  Fatty  casts,  fatty  renal  cells, 
and  fat  globules  are  often  abundant.  Blood  and'  pus  may  be  found, 
the  blood  particularly  during  the  exacerbations.  At  these  times  analysis 
shows  a  urine  similar  to  that  found  in  acute  nephritis. 

The  course  of  the  disease  is  very  irregular  and  it  is  marked  by  repeated 
remissions  and  exacerbations.  It  usually  covers  a  period  of  several 
years.  Some  patients  have  the  disease  during  all  of  childhood  and 
adolescence  and  succumb  in  early  adult  life.  Exhaustion,  acute  uremia, 
pneumonia,  and  other  complicating  inflammations  are  the  immediate 
causes  of  death. 

Diagnosis. — With  the  realization  of  the  necessity  for  the  examination 
of  the  urine  of  every  sick  child,  chronic  nephritis  will  not  escape  detec- 
tion. Chronic  digestive  disturbances,  a  persistent  debility,  anemia,  and 
dropsy  should  always  direct  attention  to  the  kidneys.  The  presence 
of  albumin  and  casts  with  defective  elimination  will  reveal  the  nature 
of  the  trouble. 

Prognosis. — ^The  prognosis  of  chronic  parenchymatous  nephritis, 
while  not  so  grave  in  children  as  in  adults,  is  decidedly  unfavorable. 
After  continuing  for  several  months  some  cases  apparently  recover. 
In  such  cases  the  pathological  process  is  arrested,  leaving  healthy  kidney 
tissue  sufficient  to  carry  on  excretion.    Other  cases  after  several  years  of 


792  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

quiescence  relapse,  and  die  from  renal  insufficiency.  The  majority  of 
the  cases  progress  with  remissions  and  exacerbations  to  a  fatal  termina- 
tion. An  abundant  urine  of  persistently  low  specific  gravity  is  indica- 
tive of  a  large  connective-tissue  growth  in  the  cortex,  or  waxy  degen- 
eration nf  the  glomerular  vessels  and  is  of  unfavorable  significance. 

Treatment. —  Taken  early,  before  extensive  jn-oductive  and  degen- 
erative changes  have  taken  place  in  the  kidney,  much  may  be  done  by 
medical  treatment  to  aid  the  arrest  of  tiie  disease.  The  same  principles 
of  treatment  are  applicable  to  children  as  to  adults.  Hygienic  measures 
should  occupy  the  first  place.  Repeated  exposures,  digestive  disturb- 
ances and  disorders  of  metabolism,  with  their  accompanying  engorge- 
ments of  the  kidney,  should  be  carefully  avoided.  Woollen  under- 
garments will  protect  from  surface  chilling,  as  exposure  to  cold 
and  wet  is  to  be  avoided.  If  it  is  possible,  an  early  removal  of 
the  patient  to  a  dry,  warm  climate  siiould  be  advised.  Return 
to  a  Northern  climate  should  not  l)e  attempted  for  two  or  three 
years.  An  out-of-door  life  with  exercise,  but  never  to  exhaustion,  is 
important. 

1  )uring  exacerbations  and  whenever  there  are  evidences  of  renal 
insufficiency  rest  in  bed  should  be  enjoined.  The  diet  should  l)e  lii)eral, 
but  simple  and  easily  digested,  and  carefully  adjusted  to  the  total  daily 
amount  of  proteids,  carbohydrates,  and  fats  to  the  needs  of  nutrition 
and  the  capacity  of  digestion.  Vegetable  and  milk  proteids  are  the 
least  irritating  to  the  kidneys,  and  a  milk  and  cereal  diet  is  an  ideal 
one  in  chronic  nephritis.  The  milk  may  be  given  diluted  with  an 
alkaline  mineral  water  like  Vichy,  or  with  the  cereal  gruels.  Light, 
succulent  vegetables  and  cooked  fruit  may  be  given  in  mofleration. 
Raw  fruit  is  better  avoided;  it  is  slow  of  digestion,  contains  but  little 
nutriment,  and  favors  the  production  of  acid  indigestion  Lgg*^,  fish, 
and  fowl  may  be  given  sparingly.  Red  meats  should  be  given  with 
great  caution  or  not  at  all.  When  it  is  difficult  to  give  sufficient  proteid 
in  the  milk  and  vegetai)les  to  repair  tissue  waste,  scraped  meat,  beef- 
juice,  and  light  broths  may  be  used  with  advantage.  The  stock  soups, 
beef-tea,  and  beef-extract  are  to  be  avoided.  An  amomit  of  fluid  suffi- 
cient to  ensure  free  elimination  should  be  insisted  upon. 

The  condition  of  the  stomach  and  l30wels  should  be  carefully  watched. 
A  daily  free  movement  of  the  bowels  is  essential,  as  a  day  or  two  of 
intestinal  intoxication  may  precipitate  an  attack  of  uremia  or  an  exacer- 
bation of  the  exudative  process.  Irrigation  of  the  colon  at  these  times 
is  of  great  value.  Cutaneous  elimination  should  be  favored  by  a  daily 
warm  bath. 

The  debility  and  anemia  demand  the  more  or  less  prolonged  use  of 
tonics.  Iron  in  small  doses,  and  quinine  and  strvehnine  are  of  value. 
Large  doses  of  iron  do  harm  by  deranging  the  digestion. 

Surgical  Treatment. — Dr.  Oorge  ]M.  Edebohls,  of  New  York,  pro- 
posed in  \SU\)  to  treat  chronic  nephritis  by  renal  decapsulation,  and 
the  reports  of  Dr.  Edelx)hls  and  others  show  what  seem  to  be  remark- 
able ri'sults  from  this  operation. 


DISEASES  OF  THE  KIDNEYS  793 

In  May,  1902,  Dr.  A.  Caille,  of  New  York,  reported  in  full  to  the 
American  Pediatric  Society  a  successful  case  in  a  girl  aged  five  years. 
The  child  had  been  under  medical  observation  for  three  years,  and  at 
the  time  of  the  operation,  February  15,  1902,  presented  the  clinical 
characteristics  and  urinary  findings  of  advanced  parenchymatous 
nephritis.  The  case  was  carefully  studied  by  Dr.  Caille,  both  before 
and  after  the  operation.  At  the  time  of  his  first  report,  three  months 
after  the  operation,  the  child  was  steadily  improving,  although  she  was 
still  anemic,  and  the  urine  showed  albumin  and  casts.  At  the  meeting 
of  the  American  Pediatric  Society  in  June,  1904,  Dr.  Caille  reported 
the  recovery  complete.  Dr.  T.  M.  Rotch  reported  to  the  same  Society 
a  case  of  advanced  nephritis  with  operation.  The  child,  a  boy  aged 
ten  years,  showed  a  temporary  improvement,  but  died  nineteen  days 
after  the  operation,  with  symptoms  of  pulmonary  edema  and  cardiac 
exhaustion.  Dr.  Tyson  {Practice  of  Medicine)  reports  one  case  in  a  girl 
aged  ten  years.  The  child  had  a  very  severe  chronic  diffuse  nephritis 
that  had  lasted  over  four  years.  At  the  time  of  operation  she  was  very 
weak  and  had  general  anasarca  and  ascites.  At  the  first  operation  one 
kidney  was  decorticated.  Dr.  Tyson  says  that  the  result  of  this  "may 
be  truly  called  marvellous."  A  month  after  the  operation  the  child  was 
apparently  well,  although  albumin  and  casts  were  still  abundant  in  the 
urine.  Following  operation  on  the  second  kidney  the  child  made  a 
prompt  recovery,  and  at  the  time  of  the  report  she  was  apparently 
well. 

Such  results  are  remarkable  and  make  surgical  interference  in  chronic 
parenchymatous  nephritis  that  has  resisted  medicinal  treatment  more 
than  justifiable.  In  commenting  on  his  case.  Dr.  Caille  states :  "From 
this  and  other  cases  which  have  come  imder  my  observation,  I  should 
be  willing  to  advise  inspection  of  the  kidneys  through  lumbar  inci- 
sion in  cases  in  which  an  acute  nephritis,  not  secondary  to  heart 
lesions,  does  not  clear  up  in  a  reasonable  time,  say  six  months,  and 
would,  furthermore,  advise  decapsulation  of  one  or  both  kidneys  should 
they  appear  swollen  and  enlarged,  with  the  hope  of  preventing  the 
acute  nephritis  from  becoming  chronic." 

Chronic  Interstitial  Nephritis. — Chronic  interstitial  nephritis  is  a 
very  rare  disease  in  early  life.  Only  a  few  cases  are  found  reported  in 
the  literature  of  diseases  of  children.  Gull  and  Sutton  recorded  the 
first  case  in  1872.  Ashby  and  Wright  met  with  two  cases  which  came 
under  observation  only  a  few  days  before  death.  Dickenson  was  able  to 
collect  five  cases  occurring  under  the  age  of  twelve  years.  Other  cases 
are  mentioned  by  Barlow,  Goodhardt,  and  Bartels.  Tyson  has  never 
met  with  a  case  in  a  child.  Guthrie  (Dondon  Lancet,  1897)  reported  seven 
cases  in  which  the  diagnosis  was  confirmed  by  autopsy.  Sawyer,  in  a 
recent  article,  reports  a  study  of  twenty-four  cases. 

The  recognition  of  the  possibility  of  contracted  kidney  in  early  life, 
and  the  more  frequent  investigation  of  the  urine  of  children  suffering 
from  obscure  chronic  disease  may  bring  to  light  a  greater  frequency  of 
chronic  interstitial  nephritis  than  is  now  suspected  (Fig.  166). 


794  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

Etiology. — 'I'he  causes  of  this  form  of  nephritis  are  obscure.  Many 
of  the  conditions  that  deterniine  the  disease  in  a(hih.s  cannot  be  operative 
in  early  life.  Chronic  alcoholism  is  hardly  possible.  Inherited  gout 
and  syphilis  are  probable  causes.  Guthrie  concluded  from  his  cases 
that  congenital  or  acquired  syphilis  was  the  most  important  etiological 
factor.  Chronic  lead  poisoning  may  produce  the  disease  as  in  adults. 
Some  cases  have  been  traced  to  a  mild  productive  nephritis  following 
one  of  the  acute  infections,  particularly  scarlet  fever.  Eustace  Smith 
considered  the  persistent  presence  of  uric  acid  deposits  in  the  urine 
as  a  premonitory  condition,  if  not  the  actual  cause  of  granular  kidney. 

Fio. 16G 


Chronic  interstitial  nephritis:  A,  C,  bloodvessels  showing  arteriosclerotic  changes;  A  endarteritis 
obliterans;  B,  tubules  with  desquamated  epithelium;  E,  cyst  caused  by  obstruction  and  dilatation  of 
tubule. 

Goodhardt  held  the  same  opinion.  Hellendall  reports  two  cases  in 
children  whose  mother  had  chronic  nephritis.  One  died  at  the  age  of 
two  years  and  the  other  at  six  months. 

The  degree  of  contraction  of  the  kidneys  in  both  cases  led  to  the 
conclusion  that  the  disease  began  in  utern.  There  was  no  history  of 
syphilis  or  any  of  the  acute  infections. 

Holt  has  met  with  two  cases  of  contracted  kidney  associated  with  con- 
genital hydronephrosis. 

Symptomatology. — "^riie  disease  is  insidious  in  onset  and  progress. 
During  the  early  stages  there  are  no  symptoms  that  direct  attention  to 
the  kitlneys,  and,  unless  the  physician  makes  it  a  rule  to  examine  the 
urine  of  sick  chiklren  under  his  care,  the  disease  may  long  continue 
unrecognized. 

The  evidences  of  seriously  impaired   nutrition  are  among  the  first 


DISEASES  OF  THE  KIDNEYS  795 

symptoms  to  fix  the  attention.  Guthrie  found  these  patients  undersized 
and  wasted.  The  wasting  Ls  of  long  standing  and  usually  is  attributed 
to  other  causes.  With  the  wasting  is  a  dry,  coarse,  and  inelastic 
skin. 

Eustace  Smith  states  that  the  gums  and  conjunctivae  are  markedly  pale, 
while  a  dusky  flush  of  the  face  from  general  capillary  congestion  masks 
the  anemia.  The  pigmentation  varies  from  a  mere  sallowness  to  a 
marked  bronzing  of  the  skin,  distributed  generally  or  in  patches.  Dropsy 
is  usually  absent.  Exceptionally  it  is  present  for  a  short  time  before 
death.  During  periods  of  intercurrent  renal  congestion  or  exudative 
inflammation,  marked  by  scanty,  albuminous  and  bloody  urine,  it  may 
be  transiently  present.  Chronic  indigestion,  with  occasional  attacks  of 
vomiting  and  diarrhea,  or  constipation  and  abdominal  pain  are  common. 
Excessive  thirst  is  frequent.  Headache,  vertigo,  dyspnea,  and  con- 
vulsions are  the  most  common  nervous  symptoms.  Visual  disturbances, 
such  as  amaurosis  or  diplopia,  and  cerebral  hemorrhage,  have  been 
noted.  These  children  are  sensitive  to  exposure,  and  bronchitis  and 
bronchopneumonia  are  frequent  complications.  Edema  of  the  lungs 
and  asthma  may  occur.  Cardiovascular  hypertrophy  with  high  arterial 
tension  is  usually  present.  With  advanced  cardiac  and  vascular  changes 
precordial  pain  and  distress  are  common. 

The  urine  in  interstitial  nephritis  is  increased  in  quantity,  pale,  and 
of  low  specific  gravity.  Sawyer  has  noted  that  in  some  instances  there 
was  a  history  of  polyuria  from  birth.  All)umin  is  usually  present,  but 
in  small  quantity,  often  only  a  trace.  As  in  the  adult,  it  may  be  absent 
for  long  periods,  or  it  may  come  and  go.  Acute  exacerbations  are 
always  marked  by  an  increased  albvmiinuria. 

The  sediment  is  light  and  contains  hyaline  casts  in  small  numbers. 
Careful  search  of  the  centrifugalized  urine  is  often  necessary  to  demon- 
strate them.  Occasionally  granular  casts  are  found,  and  during  periods 
of  increased  renal  engorgement  blood,  pus  cells,  and  epithelial  debris 
may  be  present. 

Diagnosis. — From  the  above  it  is  plain  that  chronic  interstitial  nephritis 
should  be  suspected  in  every  case  of  chronic  intestinal  derangement 
and  grave  and  persistent  interference  with  nutrition  in  childhood.  A 
polyuria  should  always  be  carefully  investigated.  The  presence  of  the 
above-noted  symptoms,  together  with  a  polyuria,  renal  insufficiency, 
persistent,  mild,  continuous  or  intermittent  albuminuria,  and  the  presence 
of  hyaline  or  granular  casts  would  determine  the  diagnosis.  In  children, 
although  not  so  frequently  as  in  adults,  occasional  hyaline  casts  are 
found  in  conditions  of  renal  irritation,  such  as  are  seen  in  lithemia  and 
other  disturbances  of  metabolism.  In  these  conditions  there  is  the 
absence  of  polyuria,  and  the  urine  is  of  normal  or  high  specific  gravity 
and  color.  Only  by  repeated  urinary  analyses  and  prolonged  clinical 
study  can  a  certain  diagnosis  be  made. 

Prognosis. — The  course  of  chronic  interstitial  nephritis  is  long  and  its 
termination  uniformly  unfavorable.  Sawyer  is  of  the  opinion  that  the 
disease  may  begin  in  childhood,  subsequently  undergo  arrest,  and  in 


796  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

adult  life,  under  favorable  conditions,  start  up  afresh  and  continue  the 
well-known  progressive  course. 

Treatment. — The  treatment  of  the  disea.se  is  principally  dietetic  and 
hytrienic.  The  diet  should  be  milk,  but  not  a  great  amount  at  a  time,  as 
the  digestive  strength  niav  be  impaired  and  the  cardiovascular  symp- 
toms increased  by  an  overal)undant  liijiiid  diet.  Water  is  needed  by 
the  system,  and  it  should  Ik>  taken  i)etween  meals.  (Vreals,  cooked  fruit, 
and  green  vegetables  may  be  added  to  the  diet  if  the  digestion  is  not 
impaired.  These  children  require  fat  and  should  be  given  butter  and 
fat  bacon.  The  skin  must  be  kept  protected  by  woollen  undergarments. 
It  is  best  to  bathe  the  children  with  tepid  water  rather  than  to  attempt 
sponging  with  cold  water.  Sunshine  and  a  warm  climate  will  add  to 
tile  comfort  and  strength  of  these  cases,  while  cold  winils  and  dampness 
will  render  them  liable  to  intercurrent  affections. 

Medicines  are  not  of  much  service.  The  action  of  the  liver  should 
be  watched  and  an  occasional  dose  of  a  mercurial  may  be  administered. 
With  high  arterial  tension  nitroglycerin  is  helpful,  and  small  doses  of 
iodide  of  potash  are  of  benefit,  lioth  of  these  drugs  may  be  continued 
for  some  time. 

PERINEPHRITIS. 

Perinephritis  Is  an  inflammation  of  the  loose  connective  and  adipose 
tissues  surrounding  the  kidney.  While  not  of  frequent  occurrence,  it 
should  alwavs  be  kept  in  mind  when  dealing  with  obscure  diseases 
of  the  abdomen. 

Etiology. — ^^rhe  disease  may  be  either  primary  or  secondary.  The 
primarv  form,  more  common  in  children,  may  be  due  to  traumatism 
or  exposure.  The  etiology  of  many  cases  is  obscure.  The  secondary 
form  of  the  disease  may  result  from  extension  of  any  neighboring 
infectious  process,  especially  in  the  kidney.  It  may  occur  as  a  compli- 
cation or  sequel  of  any  of  the  acute  infectious  diseases. 

Pathology. — The  infection,  when  not  tuberculous.  Is  usually  by  the 
ordinary  pus  organisms.  The  disease  may  terminate  in  resolution  or  in 
suppuration.  When  pus  forms,  the  abscess  cavity  may  \^e  small  or 
very  large.  As  much  as  two  or  three  pints  of  pus  have  been  evacuated 
from  one  such  abscess.  There  Is  always  a  tendency  for  the  pus  to 
burrow,  and  it  is  only  the  smallest  abscesses  that  are  well  walled  off. 
If  left  unopened,  the  abscess  may  break  through  into  any  part  of  the 
intestinal  tract  or  into  the  peritoneal  cavity.  It  may  perforate  the 
diapliragm  and  pus  be  coughed  up.  It  may  come  to  the  surface  in 
the  groin,  the  lumbar  region,  or  the  iliocostal  space.  Usually  only  one 
side  Is  affected. 

Symptoms. — In  children  the  oaset  Is  commonly  abrupt  or  it  may  be 
gradual.  There  are  fever  and  chills,  and  pain  which  may  be  referred  to 
the  loin,  to  the  groin,  or  down  the  leg.  Tentlerness  in  the  region  of  the 
affected  kidney  Is  generally  present  early.  As  the  inflammation  spreads 
there  will  be  lameness  of  the  leg.     The  thigh  is  commonly  drawn  up 


DISEASES  OF  THE  KIDNEYS  797 

and  extension  is  painful.  There  may  be  deviation  of  the  spine  with  the 
concavity  toward  the  affected  side.  Later,  a  tumor  can  be  made  out 
in  the  loin,  and  there  may  be  infiltration  of  the  skin  in  the  iliocostal 
space.  The  constitutional  symptoms  later  may  become  severe.  When 
the  onset  is  gradual,  the  pain,  tenderness,  and  stiffness  may  precede  by 
several  days  the  appearance  of  constitutional  symptoms.  No  urinary 
symptoms  are  to  be  expected  from  a  primary  perinephritis. 

Diagnosis. — Hip-joint  disease  may  be  excluded  by  a  careful  exami- 
nation. In  perirenal  abscess  there  is  no  general  joint  tenderness  and 
no  pain  connected  with  any  motion  of  the  thigh  except  that  of  extension. 
An  abscess  may  be  fully  formed  within  two  or  three  weeks  after  the  first 
symptoms  if  there  is  a  tumor.  The  opposite  prevails  in  hip-joint  disease; 
the  onset  is  insidious  instead  of  acute.  Often  an  entire  year  elapses 
before  the  development  of  the  abscess;  all  motions  of  the  hip-joint  are 
painful.    Deformity  in  hip-joint  disease  increases  much  more  slowly. 

One  must  always  exclude  the  angular  deformity  and  spinal  symptoms 
of  Pott's  disease.  When  the  pus  burrows  through  the  diaphragm  and 
appears  in  the  sputum,  a  diagnosis  of  empyema  may  be  made.  Baginsky 
reports  a  case  in  which  a  perinephritis  was  secondary  to  a  purulent 
pleuritis,  probably  tuberculous. 

The  exploring  needle  and  the  high  leukocyte  count  will  aid  in  the 
detection  of  pus  when  fluctuation  cannot  be  obtained. 

Prognosis. — In  primary  cases  the  prognosis  is  good  when  the  condition 
is  recognized  early.  Of  36  cases  observed  by  Gibney,  referred  to  by 
Holt,  all  recovered.  The  process  may  terminate  by  resolution,  in 
which  case  soreness  and  stiffness  in  the  back  disappear  very  slowly. 

In  cases  secondary  to  severe  local  processes  the  prognosis  is  not  so 
good.  When  there  is  spontaneous  opening  to  the  exterior,  healing  is 
obstinate. 

Treatment. — Rest  in  bed,  hot  fomentations,  or  the  ice-bag  to  the 
affected  area  are  primary  indications.  Abscesses  should  be  watched  for 
and  promptly  opened  with  due  surgical  precautions.  Otherwise,  the 
treatment  is  symptomatic. 


LITHIASIS. 

The  formation  of  concretions  in  the  urinary  tract  may  be  due  to 
changes  in  the  composition  of  the  urine  or  to  interference  with  its 
excretion.  The  increased  metabolism  of  infancy  and  childhood  pre- 
disposes to  this  disease.  Most  cases  in  childhood  occur  between  the 
ages  of  two  and  ten,  but  large  concretions  have  been  found  in  the  bladder 
at  birth,  and  cases  may  be  met  at  any  period  later. 

Calculi  occur  much  more  frequently  in  some  localities  than  in  others. 
In  China  and  Asia  Minor  the  condition  is  exceedingly  common,  and 
the  amount  of  calcareous  salts  in  the  drinking  water  is,  undoubtedly, 
an  etiological  factor.  A  family  history  of  gout  or  rheumatism  is  very 
common. 


798  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

Uric  Acid  Infarcts. — In  40  per  cent,  of  autopsu-s  on  infants  less 
than  two  weeks  old,  there  is  found  a  condition,  first  described  by  Virchow, 
which  he  named  uric  acid  infarct.  The  cause  is  the  formation  of  uric 
acid  in  tlie  kichiey  before  there  is  sufficient  water  in^rested  to  carry  it 
off.  Th(>  infarct  appears  in  the  <;ross  specimen  as  fiiu>,  reddish-brown 
fines,  raifiating  from  the  pelvis  of  the  kidney.  'I'he  microscope  shows 
the  characteristic  uric  acid  crystals.  There  Is  often  a  small  deposit  of 
these  crystals  in  the  pelvis  of  the  kidney.  When  diuresis  is  established, 
this  deposit  is  washed  out  and  appears  upon  the  diaper  a^  a  reddish 
deposit.  There  may  be  slight  irritation  of  the  kidney,  and  temporary 
anuria  is  common,  generally  easily  relieved  l)y  hot  applications  and 
the  ingestion  of  plenty  of  water.  Rarely  a  severe  renal  congestion  with 
sup])ression  is  observed. 

Renal  Calculus. — The  uric  acid  deposits  of  the  newborn  may  form 
a  luicleus  for  the  formation  of  renal  calculus.  The  chemistry  of  renal 
calculus  and  the  mechanism  of  fonnation  in  the  child  Is  the  same  as  In 
the  adult.  In  the  kidney  cortex  itself  a  stone  commonly  gives  no  symp- 
toms, unless  large,  when  pain  and  tenderness  in  the  kidney  region  may 
lead  one  to  suspect  its  presence.  A  history  of  the  passage  of  snudl  calculi 
is  significant,  an^l  the  skiagraph  now  offers  a  method  of  positive  diag- 
nosis. In  the  pelvis  of  the  kidney  irritation  of  the  stone  may  lead  to 
a  pyelitis,  and  by  impaction  in  the  upper  opening  of  the  ureter  cause 
])vone]ihr()sis  or  hydr()ne])hr()sis. 

Renal  Colic. — Wlu>n  a  caknilus  is  of  such  a  size  that  it  passes  down 
the  ureter  only  with  difficulty  it  may  produce  the  most  excruciating 
pain.  During  an  attack  the  child  .screams  with  {)ain,  which  is  periodic 
in  character,  resembling  severe  intestinal  colic.  The  face  is  anxious, 
flushed,  and  covered  with  perspiration.  The  child  nu\kes  frantic  c-fTorts 
to  urinate  and  succeeds  in  passing  only  a  few  drops,  often  containing 
bk)0(l  and  mucus.  Convulsions  may  occur.  In  male  children  the 
testicle  of  the  affected  side  will  be  drawn  up.  Pain  commonly  ceases 
when  the  stone  reaches  the  bladder.  Older  childri-n  will  describe  the 
pain  as  radiating  backward  and  down  the  thigh  from  the  aflFected 
kidney.  In  infants  immetliate  diagnosis  from  intestinal  colic  is  often 
impossil)le;  the  retracted  testicle  may  be  sugg(\stive.  Urinary  exami- 
nation Is  necessary  to  a  positive  diagnosis.  If  the  urine  be  examined 
innnediately  after  such  an  attack,  it  will  lie  found  to  contain  blood,  a 
considerable  amount  of  epithelium,  and  often  pus  cells.  It  may  be 
either  alkaline  or  acid;  in  the  latter  case  it  usually  contains  uric  acid 
crystals.     In  severe  kidney  irritation  there  are  hyaline  casts. 

R.  P.,  aged  11  years,  a  sturdy  boy.  For  a  few  weeks  he  had  a  di.s- 
turbed  digestion  with  abdominal  intestinal  fermentation.  While  in 
school,  about  nine  o'clock  in  the  morning,  he  was  suddenly  taken  with 
a  severe  j)ain  in  the  left  loin,  the  pain  radiating  down  the  side  and 
across  to  the  median  line  of  the  abdomen.  When  seen  two  hours  later  he 
was  still  in  great  pain.  Pulse  and  temperature  normal.  He  had  vom- 
ited. The  back  over  the  left  kidney  was  very  tender.  No  tenderness 
over  the  front  of  the  abdomen.    No  retraction  of  the  testicle.     Pain  was 


DISEASES  OF  THE  KIDNEYS  799 

not  reflected  down  the  thigh.  The  urine  contained  a  trace  of  albumin 
and  the  centrifugal  sediment  showed  numerous  red  blood  cells  and  many 
large  calcium  oxalate  crystals.  A  hot  rectal  irrigation  and  hot  stupes 
eased  the  pain,  and  by  evening  it  had  entirely  disappeared,  leaving  a 
tenderness  that  faded  by  the  following  day.  An  abundant  flow  of  urine 
followed  several  hours  of  scant  excretion. 

Vesical  Calculus. — The  symptoms  of  stone  in  the  bladder  are  some- 
what different  in  small  children  from  those  in  the  adult,  chiefly  owing 
to  the  shape  of  the  bladder.  In  the  narrow,  pyramidal  bladder  of  the 
child,  the  stone  being  in  the  most  dependent  part,  it  constantly  assaults 
the  sensitive  vesical  neck,  producing  many  reflex  symptoms;  while  in 
adults  it  may  lie  farther  back,  causing  much  less  irritation  and  no  inter- 
ference with  the  flow  of  the  urine.  There  may  be,  in  the  child,  painful 
urination,  interruption  of  the  stream,  retention,  incontinence,  hematuria, 
cystitis,  albuminuria,  reflex  pains,  rectal  tenesmus,  and  prolapse.  The 
pain  may  be  reflected  to  the  end  of  the  penis,  and  a  disposition  to  pull 
the  prepuce  is  often  noted. 

Diagnosis. — In  vesical  calculus  this  is  made  positive  by  the  sound. 
An  anesthetic  is  generally  necessary.  In  passing  the  sound,  one  must 
remember  that  the  angle  in  the  urethra  behind  the  triangular  ligament 
is  much  more  acute  in  children  than  in  adults. 

Prognosis. — Under  good  conditions  the  results  of  operation  for  renal 
calculi  have  been  encouraging.  Before  operation  is  attempted,  it  should 
be  positively  ascertained,  if  possible,  that  the  other  kidney  is  not  dis- 
eased. This  may  be  determined  by  catheterization  of  the  ureter. 
Calculous  pyelitis,  if  unoperated,  may  lead  to  perforation,  generally 
behind,  with  the  formation  of  a  fistula  in  the  lumbar  region.  Perforation 
into  the  peritoneal  cavity  with  fatal  result  has  been  reported.  The 
results  of  calculi  impacted  in  the  ureter  may  be  serious  unless  treatment 
is  prompt. 

Treatment. — No  one  now  expects  to  dissolve  a  stone  by  medicinal 
treatment.  When  once  formed,  whether  in  kidney,  ureter,  bladder,  or 
urethra,  curative  treatment  must  be  surgical. 

Gravel  may  be  washed  out.  The  administration  of  large  quantities 
of  fluid  is  the  most  essential  part  of  the  medicinal  treatment.^  The 
alkaline  mineral  waters  are  commonly  prescribed;  of  these,  Vichy  is 
one  of  the  best.  Careful  examination  of  the  urine  is  necessary,  however, 
to  intelligent  treatment.  When  an  alkaline  urine  is  depositing  a  phos- 
phatic  layer  around  a  stone,  alkalies  are  contraindicated.  In  this  case 
it  must  also  be  borne  in  mind  that  urotropin,  so  often  ^  prescribed,  is 
active  only  in  acid  urine.  For  the  irritation  from  stone  in  the  kidney, 
glycerin  has  been  recommended — 4  c.c.  to  12  c.c.  (1  to  3  dr.)— m 
solution  and  may  be  given  every  four  hours.  For  renal  colic  relief 
of  pain  is  imperative  and  demands  opium. 

Where  the  tendency  to  lithiasis  is  shown,  without  further  evidence  of 
disease  than  a  heavy,  acid  urine,  a  diet  with  a  minimum  amount  of 
meat,  and  plenty  of  milk,  should  be  ordered.  With  a  distinct  gouty  or 
rheumatic  history,  treatment  should  be  by  alkalies  and  salicylate  of  soda. 


800  DISEASES  OF  THE  GENITOURINARY  SYSTEM 


TUMORS  OF  THE  KIDNEY. 

Benign  Tumors. — The  literature  shows  that  benign  tumors  of  the 
kiihu'V  in  tliihh'cn  are  very  rare.  Aklibcrt,  out  of  fifty-one  collated  ea^es, 
found  l)Ut  three  benign  growths.  As  a  rule,  they  grow  to  only  very 
moderate  size  and  give  rise  to  few,  if  any,  symptoms.  A  limited  size, 
slow  growth,  and  the  absence  of  the  constitutional  symptoms  that 
inevitablv  attend  malignant  growtlis  would  aid  in  a  differential  diagnosis. 

Mali^ant  Tumors. — Malignant  tumors  of  the  kidney  in  early  life 
are  of  suttificnt  fre(jueney  to  make  them  of  great  clinical  importanc-e. 
The  recent  studies  of  Birch-Hirschfeld,  ^Valker,  Mc Williams  and  others 
have  given  us  a  clear  conception  of  the  pathological  relations  of  these 
interesting  growths. 

'I'hev  have  i)een  variously  described  its  carcinomata,  sarcomata, 
endotheliomata,  rhabdomyosarcomata,  etc.  Birch-Hirschfeld  demon- 
strates that  they  properly  belong  to  a  distinct  class,  which  he  designates 
embrvonal  adenosarcomata.  He  and  other  observers  recognize  car- 
cinomata among  the  ])rimary  malignant  tumors  of  children,  although 
thev  are  extremely  rare.  Walker  thinks  it  doubtful  if  carcinoma  ever 
occurs  in  young  children. 

Eberth  was  the  first  to  demonstrate  that  the  embryonal  adeno- 
sarcoma  takes  its  origin  from  remnants  of  the  AVolffian  body.  These 
tumors  always  develoj)  inside  the  kidney.  The  kidney  tissue  proper, 
however,  does  not  take  part  in  the  process,  but  becomes  compressed  and 
atrophied  as  the  tumor  grows.  The  tumor  develops  from  the  pelvic 
region,  often  splitting  the  kidney  at  this  point  so  that  what  remains 
of  the  kidney  rests  on  the  tumor  like  a  flat  cap  (Strong). 

•The  left  kidney  is  more  fre(juently  affected  than  the  right.  Occa- 
sionally both  kidneys  are  the  seat  of  growths.  At  first  the  growth  is 
slow;  later  it  Is  extremely  rapid.  Metastasis  Ls  late  and  occurs  in  about 
one-half  to  one-third  of  the  cases.  The  liver,  the  lungs,  the  other 
kidney,  aiid  the  mesenteric  nodes,  and  occasionally  the  colon,  small 
intestines,  and  adrenals  may  be  invaded.  The  infrc'Cjuent  involvement 
of  the  ureter  and  bladder  is  notable.    The  metastases  are  sarcomatous. 

Etiology.  Age. — These  tumors  have  been  found  in  the  seventh  and 
eighth  months  of  fetal  life.  They  are  most  frequent  between  the  ages 
of  six  months  and  four  years.  About  SO  per  cent,  occur  under  the  age 
of  four  years,  and  '20  j)er  cent,  under  the  age  of  one  year.  Between 
the  sixth  and  ninth  years  they  are  very  rare,  and  above  nine  years  are 
practically  unknown. 

The  reported  cases  .seem  to  be  about  equally  divided  between  males 
and  females.  Birch-Hirschfeld  considers  them  more  frequent  in  females. 
Heredity  appears  to  have  no  influence.  Among  immediate  causes, 
infectious  diseases,  traumatism,  chronic  irritations,  as  from  calculus, 
have  been  cited,  but  the  etiological  relationship  is  not  clear. 

Symptomatology. — The  characteristic  and  most  commonly  observed 
symptoms  of  renal  sarcoma  are  tumor,  hematuria,  pain,  and  cachexia. 


DISEASES  OF  THE  KIDNEYS  801 

Tumor. — In  from  one-half  to  one-third  of  the  reported  cases  this  is 
the  initial  symptom.  Occasionally  it  is  accidentally  discovered.  When 
small,  the  tumor  is  first  detected  in  the  lumbar  region.  Enlarging  often 
with  great  rapidity,  it  extends  downward  and  inward,  the  upper  border 
reaching  the  median  line  just  above  the  umbilicus  and  curving  down 
to  the  iliac  fossa.  Enlargement  may  continue  until  the  whole  abdominal 
cavity  is  filled.  Small  and  moderate  sized  tumors  are  movable  on 
palpation  and  with  respiration.  Tenderness  is  uncommon.  The  tumor 
may  be  round,  oval,  kidney-shaped,  or  nodular.  The  surface  is  smooth. 
Small  tumors  are  hard;  the  large  ones  often  soft — almost  fluctuating. 
The  colon  usually  lies  between  the  tumor  and  the  abdominal  wall,  and 
can  be  demonstrated  by  percussion  when  distended,  or  palpation  when 
flattened  and  empty.    This  is  a  very  important  diagnostic  sign. 

Hematuria,  abundant  or  manifest  only  by  the  microscope,  occurs  in 
about  one-third  to  one-fourth  of  the  cases.  It  is  often  the  initial  symp- 
tom. Of  50  collected  cases  by  Lebert,  hematuria  was  the  first  symptom. 
It  may  occur  once,  or  repeatedly,  at  longer  or  shorter  intervals. 

Pain. — Pain  is  often  an  early  symptom.  Usually  it  is  a  more  or 
less  continuous  dull  ache;  often  it  is  sharp,  severe,  or  intermittent. 
Intense  paroxysms  have  been  noted.  It  may  be  confined  to  the  side  or 
lumbar  region,  or  it  may  extend  to  the  hip,  thigh,  or  leg.  Occasionally 
it  shoots  down  to  the  testicle.  Capsule  tension  from  rapid  growth, 
pressure  on  neighboring  nerves,  ureteral  obstruction,  peritonitis,  and 
spinal  erosion  are  factors  in  pain  production.  Simple  discomfort  from 
the  size  and  weight  of  the  tumor  is  often  pronounced.  A  recent  case 
had  no  pain. 

Cachexia. — Constitutional  symptoms  are  absent  during  the  early 
part  of  the  disease.  Later,  weakness,  emaciation,  anemia,  loss  of 
appetite,  rapid  pulse,  and  symptoms  produced  by  pressure  and  inter- 
ference with  neighboring  organs  supervene.  Emaciation,  often  rapid 
and  extreme,  results  from  interference  with  digestion,  and  from  the 
absorption  of  the  toxic  products  of  tumor  metabolism.  Anemia  is  often 
marked.  Few  careful  blood  analyses  have  been  made.  Edsall  has 
noted  moderate  leukocytosis. 

The  Urine.— k  renal  hematuria,  as  above  cited,  is  the  most  char- 
acteristic urinary  symptom.  The  urine  is  usually  acid,  with  the  spec- 
ific gravity  from  1.010  to  1.040.  Sugar  has  not  been  found.  Albumin 
occasionally  is  present.  Urea  is,  as  a  rule,  diminished.  Rarely  hyaline 
and  granular  casts  and  pus  have  been  observed.  In  the  pus  cases  a 
complicating  cystitis  was  present.  Blood  clots,  necrotic  shreds,  and 
tumor  elements  have  been  observed. 

Various  pressure  symptoms  attend  the  later  period  in  the  clinical 
history  of  the  malady.  Displacements  of  the  stomach,  liver,  and  other 
organs,  with  interference  with  their  functions,  are  common.  Vomiting, 
constipation,  diarrhea  that  sometimes  is  bloody,  jaundice  from  common- 
duct  obstruction,  pigmentation  from  adrenal  invasion,  all  have  been 
observed.  Cough  and  dyspnea  from  pulmonary  metastasis  have  been 
noted  (Osier).  Ascites  and  edema  of  the  lower  extremities  are  late 
51 


g02  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

symptoms.  SiuidcMily  appearing  varicocele  and  hydrocele  are  recorded, 
rreinia  with  eoiivulsior):?,  headache,  vomiting,  and  coma  have  been 
observed.  Death  results  from  exhaustion  or  intercurrent  complica- 
tions. 

Diagnosis. — Successful  surgical  treatment  of  sarcoma  of  the  kidney 
(lej)ends,  in  large  measure,  upon  an  early  diagnosis.  The  insidious 
development  of  this  growth  makes  its  early  recognition  exceedingly  dif- 
ficult. Persistent  abdominal  or  lumi)ar  j)ain,or  a  hematuria,  demands 
a  thorough  physical  exploration  of  the  abdomen,  under  an  anesthetic 
if  necessary. 

Differentiation  has  to  be  made  between  enlargements  of  the  kidney 
other  than  sarcomata  and  enlargements  and  tumors  of  neighboring 
oro-ans.  Among  the  most  frequent  conditions  to  be  differentiated  from 
renal  sarcoma  are  tumors  and  enlargements  of  the  liver  and  spleen, 
malignant  growths  of  the  retroperitoneal  lymph  nodes,  ovarian  tumors, 
perirenal  abscess,  congenital  cysts  of  the  kidney,  hydronephrosis,  and 
pyonephrosis.  Of  the  tumors  of  the  abdomen  in  children,  sarcoma  Ls  the 
most  frecjuent.  Osier  says  that  large,  solitl,  al)dominal  tumors  in  children 
are  almost  always  sarcomata.  Sarcomata  grow  with  great  rapidity,  and 
durint^  the  earlv  part  of  their  development  are  not  attended  by  consti- 
tutional symptoms.  They  grow  from  tlie  lumbar  region,  downward 
and  inward  toward  the  iliac  fossa.  Tumors  of  the  liver  are  very  rare. 
Fattv  and  other  enlargements  of  the  liver  are  easily  recognized  from 
their  location  in  the  hypochondriac  region,  superficial  position,  and  the 
sharp  border. 

Splenic  enlargements,  although  not  frequently  met  with,  may  closely 
simulate  kidney  sarcoma.  The  spleen  does  not  enlarge  downwarfl  into 
the  iliac  fossa  and  afterward  toward  the  umbilicus.  A  sharp,  notched 
border  is  characteristic.  The  colon  lies  behind  a  splenic  enlargement 
and  in  front  of  a  sarcoma  of  the  kidney.  Inflation  of  the  bowel  may  be 
necessary  to  determine  the  relations  of  the  colon  to  an  abdominal  tumor. 
Blood  changes,  often  profound,  are  manifest  in  splenic  tumors.  Retro- 
peritoneal tumors,  when  large,  are  difficult  of  differentiation.  Their 
central  position  in  the  abdomen  is  characteristic.  Ovarian  tumors,  very 
rare  in  children,  grow  from  the  pelvis  upward. 

In  all  these  conditions  hematuria  and  other  urinary  s%Tnptoms  are 
absent. 

Congenital  cysts  of  the  kidney  are  large,  movable,  and  fluctuating. 
Constitutional  symptoms  are  absent. 

Hydronephrosis  presents  a  movable,  fluctuating  tumor.  Its  disap- 
pearance after  a  large  discharge  of  urine  is  characteristic.  Primary 
tuberculosis  of  the  kidney  offers  great  difficulty  in  diagnosis.  The 
constitutional  symptoms  and  the  urinary  findings  are  suggestive;  the 
demonstration  of  the  tubercle  bacillus  is  conclusive.  Perirenal  abscess 
and  pyonephrosis,  both  very  rare,  are  attended  l)y  pain  and  tenderness, 
swelling  in  the  back,  fever,  and  other  constitutional  symptoms.  Aspir- 
ation may  assist  in  the  differentiation  of  cysts,  hydronephrosis,  pyone- 
phrosis,   and  perirenal  abscess.     It  Is    not,  however,  without  danger. 


DISEASES  OF  THE  KIDNEYS  803 

In  all  cases  in  which  a  diagnosis  cannot  be  made,  and  particularly  if 
there  be  present  suspicious  urinary  findings,  an  exploratory  operation 
should  be  done. 

Prognosis. — Without  operation,  malignant  tumors  of  the  kidney  are 
mvariably  fatal.  In  142  cases  collected  by  Walker,  the  average  duration 
of  life  without  operation  was  about  eight  months.  Death  may  occur 
inside  of  two  montlis,  and  it  has  been  delayed  two  and  one-half  rears. 
The  soft  tumors  grow  more  rapidly  and  kill  more  quickly  than  hard 
tumors. 

Treatment. — The  treatment  is  divided  into  medical  and  surgical. 
Medical  treatment  is  palliative,  as  no  remedy  is  at  present  knoAvn  that 
controls,  in  the  least  degree,  the  progress  of  the  disease.  Coley's  serum 
may  be  used;  no  successes  have,  however,  been  reported. 

The  prominent  symptoms  demanding  treatment  are  pain  and  hema- 
turia. For  pain  produced  by  nerve  pressure,  hot  fomentations  are  of 
value.  A  large,  thick,  hot-water  compress  covered  by  an  impervious 
dressing  may  be  bound  around  the  abdomen  and  changed  every  two  to 
four  hours.  For  the  pain  of  local  peritonitis  and  capsule  tension  the 
ice-bag  is  efficient.  In  the  later  stages  and  in  the  severe  paroxysms  due 
to  ureter  obstruction,  anodynes  are  imperative.  Codeine  and  morphine 
h}^odermically ;  phenacetin  and  antip}Tin  by  the  stomach  are  most 
efficient.  Hematuria  only  exceptionally  demands  treatment.  The  pain 
of  capsule  tension  is  not  infrequently  relieved  by  hemorrhage  into  the 
pelvis  of  the  kidney.  When  the  bleeding  is  excessive  and  persist- 
ent, ergot,  2  c.c.  (k  dr.)  of  the  fluid  extract  every  three  hours,  or 
solution  of  ferric  alum,  may  be  given.  The  ice-bag  is  often  efficient. 
Adrenalin  chloride,  0.60  to  1.25  c.c.  (10  to  20  min.j  of  the  1 :  1000  solu- 
tion, may  be  administered  at  frequent  intervals  hypodermically  or  by 
the  stomach.  Proper  hygienic  surroundings,  good  nursing,  abundant 
easily  digested  food,  and  tonic  medication  prolong  life.  Pressure  symp- 
toms and  intercurrent  complications  must  be  treated  on  general  prin- 
ciples. 

Surgical  Treatment. — The  opinions  of  surgeons  as  to  the  justifi- 
ability of  operative  interference  for  renal  sarcoma  is  not  uniform. 
Gross  thought  the  operation  unjustifiable.  Aldibert,  considering  the 
high  operative  and  ultimate  mortality,  concludes  the  operation  should 
not  be  done  except  in  the  early  stages.  Chevalier  believes  that  surgical 
interference  is  not  warranted  in  children.  In  England  the  operation 
is  not  looked  upon  with  favor.  Fenwick  states  (Statistics  of  Recovery 
after  Nephrectomies),  "The  sarcomata  of  children  hardly  justify 
operation." 

The  judgment  of  American  surgeons  favors  operation.  Holt,  Jacobi, 
Abbe,  and  most  American  authorities  advise  operation.  The  best  results 
are  obtained,  as  might  be  expected,  in  early  operations  before  cachexia 
develops  and  before  damage  is  done  to  surrounding  organs.  From  a 
study  of  74  operative  cases  Walker  gives  an  immediate  mortality  of 
38.25  per  cent.,  an  ultimate  mortality  from  74.32  to  94.53  per  cent., 
and  5.47  per  cent,  of  cures.    In  my  opinion,  Walker  well  expresses  the 


804  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

situation:  "Althout^^h  tin-  t-uros  arc  very  few,  still,  in  (•()n.si(li'ratit)n 
of  the  invariahly  fatal  termination  of  this  malady  witiiout  interferenee, 
I  should  unhesitatingly  ad\ise  operation,  for  it  offers  the  only  hope, 
and,  at  worst,  it  meaiLS  only  an  accelerated  death." 


TUBERCULOSIS  OF  THE  KIDNEY. 

Although  over  70  eases  of  j)rimary  tuberculosis  of  the  kidney  in 
children  are  referred  to  in  the  literature,  in  many  of  these  the  records 
are  so  imperfect  that  one  is  led  to  doubt  the  exact  location  of  the  primary 
lesion.  Well-studied  cases,  however,  have  been  reported,  the  ages 
ranging  from  eight  montlis  to  thirteen  years.  Secondary  tuberculous 
nodules  of  the  kidneys  are  quite  common  in  general  tuberculosis,  and 
may  also  be  found  in  th?  upward  spread  of  a  genitourinary  tuberculosis, 
the  primary  focus  of  whicli  is  in  the  testicle.  This  method  of  infection 
is  rare  in  children. 

Pathology. — Miliary  tul)ercles  are  generally  found  scattered  through- 
out the  kidney  in  general  miliary  tuberculosis,  and  in  chronic  phthisis 
small  nodules  are  common.  The  upper  part  of  the  ureter  and  the  pelvis 
of  the  kidney  are  often  involved.  Perirenal  abscess  also  may  be  tuber- 
culous. The  process  differs  in  no  essential  respect  from  that  of  tuber- 
culous foci  in  general. 

SjTnptoms. — There  will  Ik-  progressive  emaciation  with  fever  fluctu- 
ating, usually  within  moderate  limits.  Vesical  irritation  may  occur  when 
the  urine  contains  much  pus.  A  decided  albuminuria  may  be  present. 
Hematuria  is  frequent.  The  sediment  usually  contains  much  pus,  red 
blood  corpuscles,  and  casts.  The  tubercle  bacillus  may  be  demonstrated, 
occurring  cither  singly  or  in  clumps.  Tumor  can  be  demonstrated  in 
about  one-half  the  cases.  When  the  disea,se  is  unilateral,  the  ureter  on 
the  affected  side  may  become  blocked,  and  for  a  few  days  normal  urine 
l)e  passed  from  the  healthy  kidney. 

Diagnosis  and  Prognosis. — The  disease  is  recognized  by  the  sympt<jms 
above  noted  and  tiie  demonstration  of  the  tubercle  bacillus.  Renal 
elements  in  the  urine  and  anything  more  than  a  trace  of  albumin  cannot 
be  accounted  for  by  cystitis. 

\\  ith  early  recognition  and  operation  there  is  some  hope  for  recovery. 
Without  operation  the  prognosis  Is  uniformly  bad.  Death  usually 
results  from  general  tuberculosis.  Uremia  may  occur,  or  perforation 
iiUo  the  jH-ritoneal  cavity  may  terminate  the  case. 

Treatment. — This  is  purely  surgical.  Vesical  irritation  may  \^ 
relieved  by  the  use  of  urotropin  and  plenty  of  water.  Injections  of  tuber- 
culin, under  careful  managem(>nt,  are  now  advised.  In  general,  a 
curative  treatment  must  be  surgical.  The  sustaining  treatment  necessary 
for  all  patients  with  tuberculosis  must  be  carried  out. 


DISEASES  OF  THE  KIDNEYS  805 


HYDRONEPHROSIS. 


Hydronephrosis  is  a  not  uncommon  congenital  condition  of  the 
kidney.     Occasionally  it  is  associated  with  other  malformations. 

Etiology. — Hydronephrosis  results  from  mechanical  obstruction  of  the 
outflow  of  the  urine  at  some  point  along  the  urinary  tract,  although  it 
is  not  always  possible  to  demonstrate  it  on  autopsy. 

Among  the  conditions  in  the  ureter  causing  obstruction  are:  twisting, 
contraction,  or  obliteration;  a  pinhole  vesical  orifice,  an  acute  angular 
junction  with  the  pelvis  of  the  kidney,  cysts  in  the  mucous  membrane, 
and  impacted  calculus,  with  or  without  ulceration  and  cicatrization. 
While  most  frequently  in  the  ureter,  the  obstruction  may  be  in  the 
bladder,  urethra  or  prepuce. 

Pathology. — The  pelvis  of  the  kidney  is  dilated  into  a  sphenoidal 
sac,  the  calices  widened  and  forming  pockets.  The  cortical  and  medul- 
lary substance  of  the  kidney  is  compressed  and  often  destroyed,  leaving 
in  the  place  of  the  kidney  only  a  loculated  cyst.  The  hydronephrotic 
kidney  may  be  smaller  than  the  normal  kidney,  or  it  may  form  a  tumor 
filling  the  greater  part  of  the  abdominal  cavity. 

The  contained  fluid  may  be  pale  and  clear  or  dark,  brownish, 
and  colloid  in  consistence.  It  contains  sodium  chloride,  urea  and 
urates  and  epithelial  cells.  Urea  is  often  present  in  but  a  very  small 
quantity. 

The  ureters  are  elongated,  sacculated,  and  dilated,  and  when  the 
obstruction  is  in  the  lower  part  of  the  urinary  tract  the  bladder  is  hyper- 
trophied.  The  remaining  kidney  tissue  is  often  the  seat  of  a  chi'onic 
diffuse  inflammation. 

Ssnnptomatolcgy. — Hydronephrosis  may  be  unilateral  or  bilateral. 
When  unilateral  and  the  other  kidney  is  normal,  there  will  be  no  symp- 
toms unless  the"  hydronephrosis  reaches  a  suflficient  size  to  form  an 
abdominal  tumor.  According  to  Holt,  this  is  most  frequently  noted 
between  the  third  and  eleventh  years.  Nephritis  of  one  or  both  kidneys 
is  not  infrequently  a  complication. 

When  bilateral,  chronic  nephritis  or  pyelitis,  or  both,  supervenes  in 
the  early  months  of  life,  the  general  and  local  symptoms  of  that  con- 
dition are  present,  and  usually  determine  a  fatal  result  before  the 
development  of  a  tumor.  The  hydronephrosis  can  in  these  cases  only 
be  suspected  and  it  is  commonly  overlooked. 

Prognosis. — Infants  with  a  double  hydronephrosis  live  but  a  few 
montKs,  dying  of  nephritis,  marasmus,  or  some  other  condition  dependent 
upon  the  deranged  kidneys.  With  a  single  hydronephrosis  the  outlook 
is  gloomy,  but  with  one  normal  kidney  surgical  interference  may  bring 
about  a  recovery. 

Treatment. — This  is  surgical,  but  some  benefit  may  be  had  from  the 
administration  of  urotropin. 


806  DISEASES  OF  THE  OENITOUBJNABY  SYSTE3I 


CYSTIC  DEGENERATION  OF  THE  KIDNEY. 

This  coiiditioii  is  occasionally  met  whU  in  infants  dying  in  the  first 
year  of  litV.    Tiiciv  arc  nsnaliy  no  symptoms  referable  (o  the  kidneys. 


Fir.,  lf.7 


Misplacement  of  left  kidney  in  female  infant. 


The  kidneys  are  fonnd  to  be  small  and  the  r(>nal  ti.ssnc  converted 
into  \iiT(rc  nnmbers  of  conolomerated  cysts  of  \arying  sizes.  The 
glandular  stnictnre  is  more  or  less  replaced  by  loose  connective  tissue. 


DISEASES  OF  THE  KIDNEYS  807 


MALPOSITION  OF  THE  KIDNEY. 

Malposition  of  the  kidney  is  a  rare  condition.  In  about  25  per  cent, 
of  the  cases  the  left  kidney  is  the  one  that  is  displaced.  The  displace- 
ment is  usually  downward  and  the  kidney  may  be  found  lying  in  the 
hollow  of  the  sacrum. 

There  are  no  symptoms  referable  to  the  kidney  and  the  condition  is 
not  necessarily  of  clinical  importance.  Fig.  167  shows  the  left  kidney 
displaced  downward  lying  behind  and  a  little  above  the  uterus.  The 
infant  died  of  an  acute  bowel  infection. 


MOVABLE  KIDNEY. 

The  attention  given  in  the  last  few  years  to  movable  kidney  has 
revealed  its  frequency  in  the  adult  and  its  occasional  occurrence  in  the 
child.  A  number  of  isolated  cases  have  been  reported.  Comby  reported 
18  cases,  2  being  under  the  age  of  three  months  and  6  between  one  and 
ten  years.  16  of  the  cases  were  girls  and  2  were  boys,  about  the  pro- 
portion met  with  in  adult  life. 

Etiology. — The  great  predominance  of  the  condition  in  the  female, 
both  child  and  adult,  would  tend  to  show  that  the  conformation  of  the 
female  abdomen  predisposes  to  it.  Chronic  dyspepsia  with  gastro- 
ectasia  is  an  almost  luiiformly  present  condition  and  probably  bears  an 
etiological  relationship.  Many  writers  believe  the  condition  congenital, 
dependent  upon  too  long  a  pedicle. 

Symptomatology. — In  many  cases  the  condition  is  latent  and  gives 
rise  to  no  symptoms  directly  referable  to  the  kidney.  Paroxysmal  pain 
in  the  upper  or  lower  quadrant  of  the  abdomen  is  sometimes  present, 
appearing  particularly  after  muscular  exertion  or  fatigue. 

The  palpable  kidney  is  usually  sensitive.  Attacks  of  nausea  and 
vomiting  are  frequent,  but  may  be  dependent  upon  the  associated  gastric 
disease.  Rarely  twisting  of  the  ureter  and  occlusion,  with  the  formation 
of  hydronephrosis,  has  been  observed. 

Diagnosis. — The  diagnosis  is  often  difficult,  particularly  in  the  young 
infant.  The  presence  of  a  hard,  round,  movable  tumor  in  the  upper 
quadrant  of  the  abdomen  and  replaceable  under  the  ribs  is  characteristic. 
Appendicitis,  perinephritis,  stone,  and  renal  growths  of  the  kidney  have 
to  be  differentiated. 

The  following  is  an  example  of  the  condition:  Girl,  aged  three  and 
one-half  years.  She  was  seen  in  consultation  for  chronic  intestinal 
indigestion,  with  impaired  nutrition.  From  infancy  the  child  was  subject 
to  frequent  attacks  of  vomiting,  with  abdominal  pain  and  sometimes 
diarrhea.  The  attacks  came  without  apparent  dietetic  cause.  At  the 
time  of  the  consultation  the  child  was  having  one  of  these  disturbances. 
With  no  history  of  dietetic  error,  she  had  vomited  the  night  before  and 
had  pain  and  diarrhea.    The  abdomen  was  distended  and  tender.    The 


808  DISEASES  OF  THE  GENITOURINARY  SYSTEM 

liwr  was  cnlartjod,  the  lower  border  one*  and  one-half  inehes  helow  the 
ribs.  The  kidney  was  pal})able  below  the  innbilieal  line,  wius'inildly 
sensitive,  and  readily  slipped  baek  under  the  ribs.  The  ease  was  not 
under  observation  long  enough  to  determine  whether  the  movable 
kidney  was  a  eoineidenee  of  the  intestinal  catarrh  or  bore  an  etiological 
relation  to  it,  although  mider  a  carefully  regulated  diet  for  two  weeks 
the  svni])t()ins  of  indigestion  disappeared. 

Treatment. — Medicinal  treatment  is  of  limited  value.  A  properly 
fitting  bandage,  while  not  holding  the  kidney  in  position,  prevents  by 
general  pressure  its  too  free  excursion  from  its  bed.  i\Iost  important 
is  the  pr()j)er  treatment  of  the  associated  digestive  disturbance  and  the 
relief  of  the  dilated  stomach.  During  ])eriods  of  unusual  pain,  rest  in 
bed  may  be  essential  and  a  properly  fitting  bandage  may  be  tried. 

In  severe  cases  surgical  treatment  is  advisable. 


SECTION  X. 

DISEASES  OF  THE  BLOOD,  LYMPHATIC 
SYSTEM  AND  GLANDS. 

By  JOHN  RUHRAH,  M.D. 


CHAPTER    XXXII. 

THE    BLOOD-ANEMIA— CHLOROSIS— LEUKEMIA-PURPURA— 

HEMOPHILIA. 

THE  BLOOD. 

The  present  state  of  knowledge  of  the  blood  conditions  of  infants 
and  young  children  is  very  incomplete.  Much  remains  to  be  learned 
and  much  of  what  is  known  is  obscure  and  difficult  of  interpretation. 
For  the  general  purposes  of  diagnosis  and  prognosis,  however,  the 
results  of  blood  examinations  are  in  the  main  satisfactory.  Every  prac- 
titioner should  be  equipped  to  make  routine  blood  examinations  when 
required.  This  includes  counting  the  red  and  white  blood  cells,  an 
estimation  of  the  hemoglobin,  and  a  microscopic  study  of  fresh  or  dried 
and  stained  slides. 

Differential  Counting. — It  is  often  desirable  to  determine  the  percent- 
age of  the  various  kinds  of  leukocytes  present.  To  do  this  about  five 
hundred  leukocytes  should  be  counted.  Counting  is  best  done  by 
using  a  mechanical  stage,  but  this  is  not  essential.  It  is  best  to  start 
at  one  corner  of  the  slide  and  move  across  one  field  at  a  time,  noting 
the  number  and  kind  of  leukocytes  present.  Having  reached  the  other 
side  of  the  specimen,  a  field  lower  down  is  counted  and  the  reverse 
direction  taken,  thus  following  out  a  serpentine  course  until  the  entire 
slide  has  been  gone  over  (Figs.  168,  169,  170  and  171). 

Red  Blood  Cells. — ^The  number  of  these,  the  relative  hemoglobin 
content,  the  size,  shape,  and  staining  reaction  are  important.  It  should 
be  noted  whether  any  abnormal  cells  are  present.  The  size  is  on  an 
average  7.5/i.  In  disease  they  may  be  very  small,  4//  to  1//,  so-called 
microcytes.  These  are  seen  in  some  cases  of  chlorosis  and  in  severe 
acute  and  chronic  anemias.  The  size  may  be  increased  to  10//  or  20/^. 
These  are  called  megalocytes.    They  are  seen  in  severe  anemias,  usually 

(  809 ) 


810    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 


of  some  iluratioii.     They  arc  supposed,  by  some,  to  indicate  an  effort 
at  regeneration  of  the  blood. 

The  cells  nuiv  be  niisshai)(>n  (poikilocytosis),  and  this  is  seen  in  severe 
crrades  of  aneniia.  Care  should  be  taken  not  to  mistake  artefacts  for 
poikilocytes. 


Tin. 1C8 


Fio. 169 


Proper  method  of  holdiug  a  cover-glass.    (Cabot.) 


IlUistratiiig  the  position  of  cover- 
glass  during  the  spreading  of  blood 
films.    (Cabot.) 


When  stained  with  hematoxylin  and  eosin  or  Ehrlich's  tricolor  dye 
the  red  blood  cells  sometimes  exhibit  curious  staining  reactions.  They 
stain  a  brownish  color,  "^rhis  is  known  as  polychromasia.  It  is  seen 
normally  in  fetal  blood  and  in  bone-marrow  cells.  Pathologically  it  Is 
seen  in  severe  anemias. 


Fio. 170 


0.100  mm. 

i  ^^^ 

4fixj  mm. 

1  ^y 

^-      '  ^ 

Thoma-Zeiss  blood-roiinting  apparatus:  a,  slide  with  counting  chamber;  b,  sectional  view  of 
slide  with  counting  chamber ;  c,  ruled  di.sc  for  counting  ;  .S.  ]U.,  pipette. 

Grawitz  has  described  a  granular  degeneration  of  the  red  blood  cells 
in  pernicious  anemia  when  blue  granules  or  areas  are  seen. 

Nuclrated  red  cells  are  seen  in  fetal  life,  in  premature  infants,  and  just 
after  birth.  They  disappear  after  a  short  time  in  full-term  infants. 
After  that  their  occurrence  is  pathological. 


DISEASES  OF  THE  BLOOD 


811 


Fig. 171 


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Appearance  of  blood  in  the  Thoma- 
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There  are  two  varieties :  1.  Normoblasts,  which  are  the  size  of  a  normal 
red  blood  cell,  but  which  have  a  tlark-staining  nucleus.  These  are  seen 
in  mild  and  severe  anemia,  chlorosis,  leukemia,  etc.  In  children  they 
may  be  seen  in  bone-marrow  disease  and  even  in  severe  leukocytosis. 
2.  Megaloblasts,  gigantohlasts,  are  very  large  cells,  10/^  to  20y"  in  diameter, 
showing  polychromasia  and  several  different  kinds  of  nuclei.  They  are 
observed  in  young  infants,  as  mentioned 
above.  In  moderate  anemias  some  may 
be  seen.  If  present  in  a  severe  anemia 
in  great  numbers  a  diagnosis  of  perni- 
cious anemia  should  be  made.  This  is 
usually  a  primary  pernicious  anemia,  but 
great  numbers  may  occur  in  the  severe 
or  pernicious  type  of  secondary  anemia. 

The  number  of  red  blood  cells  in 
infancy  is  somewhat  above  that  of  later 
life.  At  birth  the  average  is  from 
4,500,000  to  6,500,000  per  c.mm.  This 
falls  during  the  first  weeks,  and  for  the 
first  year  of  life  an  average  of  5,500,000 
may  be  given  for  healthy  infants  and 
5,000,000  as  an    average  for  childhood. 

The  hemoglobin  is  also  high  at  birth,  usually  above  100  on  von 
Fleischl's  scale.  It  sinks  to  about  100  by  the  second  week  and  falls 
until  about  the  third  month.  From  this  time  to  the  second  year  it  is 
low,  ranging  between  60  and  SO.  After  the  second  year  it  increases  until 
about  puberty.  It  should  be  borne  in  mind  that  the  hemoglobin  is 
extremely  variable  in  childhood. 

The  specific  gravity,  alkalescence,  and  other  things  often  mentioned 
have  as  yet  no  great  practical  interest. 

The  White  Blood  Cells. — These  are  of  particular  interest  and  are  of 
various  kinds.     Ehrlich's  classification  is  as  follows: 

Lymphocytes:  Sviall  Mononuclear  Leukocytes.— These  are  small  cells 
about  the  size  of  a  red  blood  corpuscle.  The  nucleus  occupies  the 
greater  portion  of  the  cell.  The  nucleus  stains  well  with  basic  dyes, 
but  not  as  deeply  as  the  narrow  rim  of  protoplasm  which  surrounds  it 
(basophile). 

Large  Mononuclear  Leukocytes  and  Transitional  Forms.— These  are 
large  cells  two  or  three  times  larger  than  the  preceding.  The  nucleus  is 
oval,  usually  not  quite  in  the  centre,  and  stains  with  basic  dyes.  It  does 
not  stain  as  deeply  as  the  nucleus,  but  is  always  much  darker  than  the 
protoplasm  which  surrounds  it.  The  protoplasm  is  clear,  contains  no 
granules,  and  forms  a  considerable  portion  of  the  cells  (basophilic). 

The  transitional  forms  resemble  slightly  the  following  in  that  the 
nucleus  is  more  or  less  irregular  in  shape  and  stains  more  deeply  than 
in  the  simple  large  mononuclear  form.  The  protoplasm  may  contain 
a  few  granules  which  stain  only  with  neutral  dye  (hence  neutrophilic 
granules). 


812    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

Poli/inorplionuclcar  iinifwpltilir  Iriikoci/tc.^,  called  (Generally,  for  coii- 
veuience,  polynuclcars.  These  are  slightly  smaller  than  the  })reee(liiig. 
The  nucleus  consists  of  several  pieces  joined  hy  narrow  strips  of  proto- 
plasm. 'I'he  nucleus  stains  deeply  with  basic  dyes.  The  protoplasm 
stains  with  acid  dyes  and  instead  of  being  clear  is  filled  with  numerous 
small  granules  which  stain  only  with  neutral  dyes. 

Eosinophiles  are  in  general  appearance  like  the  preceding  except  the 
nucleus  has  usually  hut  two  parts.  The  grannies  are  larger  and  stain 
deeply  with  acid  dyes  (eosin  for  example). 

Masf  cells  are  seen  only  occ-asionally.  They  resemble  the  polynuclcars 
in  general  appearance  but  the  nucleus  may  be  mononuclear  or  poly- 
nuclear  and  the  granules  stain  only  with  basic  dyes. 

Abnormal  White  Cells.  Mi/eloci/tcs. — These  are  large  cells  which 
normally,  like  the  nucleated  red  cells,  belong  in  the  bone-marrow.  They 
are  occasionally  foimd  in  the  lilood  in  certain  diseases,  as  diphtheria, 
and  in  starvation  antl  various  toxemias,  as  well  as  in  splenomyelogenous 
leukemia,  where  they  are  one  of  the  features  of  the  disease.  Stained 
with  Ehrlich's  tricolor  dye  they  are  seen  as  large  round  or  nearly 
round  cells.  They  have  a  large  nucleus  which  takes  but  a  pale  stain, 
and  the  surrounding  protoplasm  is  filled  with  neutrophilic  granules. 
Sometimes  the  granules  may  be  more  or  less  basophilic.  The  size  is 
usually  larger  than  any  of  the  cells  described  above,  but  the  diagnosis 
of  a  myelocyte  is  made  on  the  staining  reaction  rather  than  mere  size, 
as  they  may  be  small. 

Eosinophilic  Myelocytes. — These  are  like  the  preceding  except  the 
granules  are  stained  by  acid  dyes  (oxyphilic). 

In  addition  to  the  above  other  cell  forms  are  seen  occasionally,  most 
important  of  which  are  degenerated  leukocytes.  These  are  leukocytes 
staining  feebly  or  intensely,  usually  without  a  nucleus,  or  with  vacuoles. 
Non-gramilar  myelocytes  may  also  be  seen  in  any  very  severe  anemias. 

Blood  plates  are  found  in  normal  blood,  but  are  usually  overlooked. 
They  are  generally  seen  clumped  together.  They  are  half  the  size  of 
a  red  blood  cell,  are  colorless,  and  have  no  ameboid  movement.  Their 
clinical  significance,  if  they  have  any,  is  not  known. 

Blood  Dust. — In  fresh  blood  there  are  seen  numerous  highly  refractile, 
actively  dancing  bodies.  These  are  supposed  to  be  the  granules  set 
free  from  the  eosinf)philes.  They  should  not  be  mistaken  for  malarial 
parasites. 

Frequency  of  Various  Forms  of  T.EUKorYTEs. 

Infancy.  Adult.    (Cabot.) 

Lymphocytes 40  to  60  20  to  30  per  cent. 

Large  mononuclears        4  "     8       " 

Polynuclcars 20  to  40  G2  "   72 

Eosinophiles 2  "    4  1/2  "     4        " 

Mast  cells IMO  "  ],'2 

The  total  number  of  leukocytes  in  th?  blood  in  infancy  is  somewhat 
greater  than  adults.  They  are  highest  at  l)irth,  from  12,000  to  25,000. 
They  fall  rapidly  during  the  first  few  days  and  reach  an  average  between 
9000  and  14,000.     During  childhood  the  average  is  still  lower,  from  6000 


PLATE  XXI. 


i^^Sfe 


13 


Note  the  size  of  the  various  leukocytes,  as  compared  with  the  red  corpuscles  at  15.  Figs. 
1,  2,  and  6  represent  the  most  common  forms  of  the  small  type  of  lymphocytes;  3  and  5 
belong  to  the  same  group,  but  are  manifestly  atypical;  3  shows  the  knob-like  projections; 
4  represents  the  large  type  of  the  lymphocyte,  and  shows  the  vacuolated  appearance  of  the 
protoplasm,  which  is  so  commonly  seen.  The  metachromatism  of  the  protoplasm,  how- 
ever, does  not  appear  here  as  in  nature.  7  and  8  are  representatives  of  the  large  variety  of 
mononuclear  leukocytes;  9  may  be  classed  as  a  transition  form,  which  is  as  yet  devoid  of 
granules;  13  represents  a  neutrophilic  myelocyte,  14  an  eosinophilic  myelocyte,  10  a 
neutrophilic  polynuclear  leukocyte,  H  an  eosinophile  of  the  same  type,  and  12  a  typical 
basophilic  leukocyte. 

The  preparations  were  stained  with  the  eosinate  of  methylene  blue  and  drawn  to  scale. 
(Bausch  &  Lomb,  eye-piece  1  inch,  objective  V12.)     (Simon.) 


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DISEASES  OF  THE  BLOOD  813 

to  12,000.  Further  study  Ls  needed  to  determine  the  number  and  variety 
of  the  various  forms  of  leukocytes  at  different  ages.     (See  Plate  XXI.) 

The  Significance  of  Blood  Changes.— Red  blood  cells  are  diminished  in 
primary  and  secondary  anemias,  are  about  normal  in  chlorosis,  and  are 
increased  in  cyanosis.  They  are  increased  in  high  altitudes  and  in  sea 
air.    This  may  be  taken  advantage  of  in  the  treatment  of  anemia. 

Hemoglobin  is  diminished  in  all  forms  of  anemia.  In  chlorosis  and 
secondary  anemia  the  corpuscle  contains  less  than  normal.  In  per- 
nicious anemia  it  may  contain  more  than  normal,  but  the  total  quantity 
is  diminished  because  the  total  number  of  red  cells  is  also  diminished. 

In  the  cyanosis  of  congenital  heart  disease  there  is  a  concentration  of 
the  blood.  There  Is  an  increase  in  the  number  of  red  blood  cells,  from 
6,000,000  to  12,000,000  being  noted.  There  is  increased  specific  gravity 
and  increased  hemoglobin.  In  some  cases  there  may  be  an  increase  of 
several  thousand  per  millimetre  in  the  leukocytes.      (See  Plate  XXII.) 

LympJiocytes  are  normally  much  more  abundant  than  in  adults. 
INIany  of  the  so-called  cases  of  lymphocytosis  are  only  the  normal 
findings  of  early  life.  In  many  severe  diseases,  as  in  gastroenteritis, 
the  blood  of  children  tends  to  revert  to  the  infantile  type  and  there  is 
a  great  increase  in  the  number  of  IjTuphocytes.  These  cells  are  increased 
in  whooping-cough,  rickets,  scurvy,  and  especially  in  hereditary  syphilis. 
The  greatest  increase  is  in  lymphatic  leukemia.  The  increase  must  be 
both  relative  and  absolute  before  making  the  diagnosis  of  lymphocytosis, 
for  if  the  polynuclear  neutrophiles  are  diminished  there  may  be  an 
apparent  increase  in  the  lymphocytes.  In  syphilis  where  there  is  doubt 
as  to  the  diagnosis,  an  increase  in  the  lymphocytes,  especially  if  coupled 
with  an  increase  in  the  eosinophiles,  points  to  syphilis.  Cabot  has  sug- 
gested that  the  number  of  l^Tiiphocytes  in  the  blood  of  a  child  might  be 
taken  as  a  measure  of  its  development,  excluding  causes  for  leukocytosis, 
the  standard  being  the  normal  percentage  for  a  child  of  the  given  age. 

Leukocytosis. — This  may  be  physiological  or  pathological.  Physio- 
logical leukocytosis  of  all  kinds  is  exaggerated  in  infancy  and  childhood. 
The  leukocytosis  of  the  newborn  has  been  considered.  Fasting  lowers 
the  number  of  leukocytes,  while  taking  food  increases  them.  After  a 
meal  30,000  leukocytes  may  be  counted.  This  increase  begins  about 
an  hour  after  the  meal  and  lasts  several  hours.  There  is  leukocytosis 
after  exercise,  massage,  and  cold  baths.  A  leukocytosis  is  frequently 
seen  just  before  death.    This  is  called  agonal  leukocytosis. 

Pathological  leukocytosis,  affecting  chiefly  the  polynuclear  neutro- 
philes, occurs  in  numerous  conditions,  as  in  malignant  tumors,  in 
toxemias,  ow4ng  to  various  drugs  or  ex-perimental  procedures,  after 
severe  hemorrhages,  and  especially  in  inflammatory  conditions.  Of 
great  importance  are  the  diseases  where  there  is  pus  formation,  as  in 
abscesses,  peritonitis,  osteomyelitis,  as  well  as  septicemia  and  pyemia. 
In  empyema  it  is  of  some  diagnostic  value  and  a  sudden  increase  in 
the  leukocytes  late  in  a  pneumonia  or  during  convalescence  frequently 
means  an  empyema.  It  is  useful  in  differentiating  a  catarrhal  from  a 
purulent  appendicitis.     Too  much  stress  should  not  be  laid  on  the 


814    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

importam-e  of  IcMikocytosis  in  surgical  dLscascs  of  very  youn<,'  c-hildren. 
The  subjeet  needs  further  investifjjatiou. 

In  minor  infections  the  leukocytosis  is  of  a  niihl  grade,  in  moderate 
or  severe  inflammations  where  the  resistance  is  good  it  is  marked,  but 
in  very  severe  infections  there  may  be  no  leukocytosis. 

In  pneumonia  there  is  a  reduction  in  the  hemoglobin  and  red  blood 
cells,  and  in  all  but  exceptionally  mild  or  very  severe  cases  a  marked 
leukocytosis.  In  children  this  Is  especially  marked,  50,000  being  fre- 
(|ueutly  noted.  The  absence  of  leukocytosis  in  severe  cases  means  a 
bad  j)r()gn()sis.  In  obscure  or  in  centrally  situated  ])neuin()nias  the 
leukocytosis  may  be  of  considerable  diagnostic  value,  'riie  eosin()[)hiles 
arc  diminished  or  absent  and  their  reappearance  is  taken  to  mean  that 
the  acme  of  the  disease  has  been  passed. 

In  diphtheria  there  Is  a  normal  red  blood  count  which  falls  after  the 
third  or  fourth  day.  The  hemoglobin  also  diminishes.  The  return  to 
normal  is  slow.  In  cases  treated  with  antitoxin  the  loss  of  red  blood 
cells  and  of  hemoglobin  is  not  so  great.  Leukocytosis  is  ])resent  in 
n(>arly  all  instances.  It  may  be  absent  in  very  mild  or  very  severe 
c-as(\s.  Engxd  found  myelocytes  in  very  severe  cases.  Where  they 
exceeded  2  per  cent,  the  patients  died. 

Scarlet  fever  results  in  a  diminution  of  the  red  l)lood  c(>lls  and  of 
hemoglobin.  The  leukocytosis  varies  with  the  intensity  of  the  disease. 
It  reaches  its  height  one  or  two  days  after  the  appearance  of  the  rash 
and  falls  gradually,  persisting  after  the  eruption.  The  eosinophiles  are 
said  to  increase  after  two  or  three  days  and  reach  a  maximum  of  from 
8  to  15  per  cent,  in  two  or  three  weeks.  They  then  fall  gradually, 
reaching  normal  about  the  sixth  week.  According  to  Neusser  the 
eosinophiles  are  increased  in  favorable  cases  and  decreased  in  the 
unfavorable  ones.  In  diiferentiating  measles  and  scarlatina,  a  leuko- 
cytosis by  the  third  day  points  to  scarlatina. 

IV hooping-cough  shows  a  marked  and  early  leukocytosis.  This  aj>pears 
in  the  catarrhal  stage  and  disappears  slowly  with  complete  convalescence. 
The  number  averages  25,000  to  30,000,  and  it  is  pronounced  in  children 
under  four  years  of  age,  al)out  one-half  the  white  cells  in  these  cases 
JKMng  lymphocytes.  This  Is  of  value  in  difYcrentiating  whoopingwough 
from  spasmodic  cough  caused  by  pressure  of  tuberculous  bronchial  or 
mediastinal  lymph  nodes. 

Varicella. — PVw  observations  have  been  made.  Engel  has  reported  mod- 
erate polynuclear  neutroj)hili('  leukocytosis  with  eosinophilia  after  healing. 

Vaccinia. — Leukocytosis  begins  on  the  third  or  fourth  day  after 
inoculation  and  then  falls  to  the  seventh  or  eighth  day,  when  the  leuko- 
cytes may  even  fall  below  normal.  There  is  a  secondary  leukocytosis 
on  the  tenth  or  twelfth  day,  lasting  from  two  to  six  days  (Sa])otka). 

Acut  articular  rhcuinatism  shows  an  anemia  with  leukocytosis  vary- 
ing in  a  general  way  with  the  severity  of  the  disease.  It  has  no  diagnostic 
value,  however,  as  the  same  is  found  in  other  arthritides. 

Meningitis. — Septic  meningitis  has  a  leukocytosis.  Cerebrospinal 
fever  has  it  in  about  two-thirds  of  the  cases.     In  tuberculous  meningitis 


DISEASES  OF  THE  BLOOD  gl5 

there  is  usually  no  leukocytosis,  although  there  are  exceptions  to  this. 
For  the  first  two  leukocytosis  is  often  of  value  in  excluding  coma  from 
other  causes  or  typhoid  resembling  meningitis.  There  is  leukocytosis 
in  brain  abscess. 

In  quite  a  number  of  diseases  there  is  no  leukocytosis  unless  there  are 
complications.  It  is  important  to  bear  these  in  mind.  The  most 
prominent  are  tuberculosis  in  its  various  forms,  t}^hoid  fever,  malaria, 
mumps,  measles,  and  German  measles.  Influenza  is  said  not  to  have 
leukocytosis  in  most  cases. 

Leucopenia,  or  a  diminution  of  the  white  blood  cells,  may  be  present 
at  times  in  any  of  the  diseases  just  mentioned,  in  malnutrition,  usually 
in  very  severe  anemias,  and  in  leukemia  when  complicated  by  an 
infectious  disease,  and  in  a  few  other  conditions. 

Eosinophilia,  or  an  increase  in  the  number  of  eosinophiles,  is  found 
in  a  very  large  number  of  conditions  and  is  of  some  diagnostic  and 
prognostic  value.  Among  the  conditions  where  it  is  found  are:  infection 
of  the  body  with  most  of  the  annual  parasites,  as  in  trichinosis,  anky- 
lostomiasis, and  the  various  forms  of  intestinal  worms,  ox}'uris,  ascaris, 
and  the  tapeworm;  in  malignant  tumors,  in  many  other  diseases  both 
acute  and  chronic ;  especially  pemphigus  and  urticaria ;  in  purpura  and 
hemorrhagic  exudate;  in  diseases  w^here  the  bone-marrow  is  affected; 
in  leukemia,  in  scarlet  fever,  and  sometimes  in  rheumatism,  and  after 
fevers.  The  presence  of  eosinophilia  shows  active  regeneration  of  the 
blood  and  is  looked  upon  as  a  favorable  sign  in  severe  anemias  follow- 
ing hemorrhage.  It  is  also  supposed  to  mean  a  good  prognosis  in  scarlet 
fever  and  chlorosis. 

Mast  cells,  according  to  Ewing,  are  seen  with  greater  frequency  in 
patients  from  the  lower  classes  than  in  the  well-to-do.  They  may  be 
increased  in  some  cases  of  leukemia  and  have  been  seen  in  other 
diseases. 

Myelocytes  are  seen  under  several  conditions.  They  are  present  in 
large  numbers  in  most  cases  of  leukemia.  They  may  be  seen,  however, 
in  small  numbers  in  severe  anemias  of  any  form,  in  the  leukocytosis 
of  some  infections  (diphtheria)  and  after  any  severe  blood  disturbance, 
as  uremia,  asphyxia,  and  the  like. 


ANEMIA. 

The  anemias  of  infancy  and  children  are  deserving  of  further  study. 
Our  knowledge  is  as  yet  chaotic  and  fragmentary.  Several  things  must 
be  borne  constantly  in  mind.  The  age  of  the  child  and  the  blood  con- 
dition which  is  normal  to  that  age  are  important.  If  a  child  is  backward 
in  development  its  blood  corresponds  to  the  age  of  a  child  which  it 
resembles.  There  is  a  tendency  to  revert  to  the  embryonic  t}^e  or  to 
the  type  of  the  younger  child.  Normoblasts  may  be  seen  in  early 
infancy  and  have  no  especial  significance.  Leukocytosis  may  be  present 
in  a  severe  anemia.     In  infants  a  large  spleen  may  be  seen  with  any 


816    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

form  of  anemia.  "All  the  signs  by  which  disease  is  shown  by  the  blood 
of  adults  arc  ("xajjjijcratcd  in  cliildreii."  (Cabot.) 

Simple  or  Secondary  Anemia. — Simple  or  secondary  anemia  is  that 
which  Ls  tine  to  some  known  cause  in  contradistinc-tion  to  primary  or 
the  so-called  pernicious  anemia  when  the  cause  is  unknown  and  where 
a  certain  blood  condition  exists.  Some  of  the  anemias  designated  as  per- 
nicious might  be  classed  as  secondary  now,  as  they  have  been  found  due 
to  certain  intestinal  j)arasites.  As  the  blood  changes  are  the  same  as 
in  the  pernicious  anemia,  they  are  considered  with  that  disease.  Simple 
anemia  may  be  of  any  grade  from  the  most  trifling  to  the  most  severe, 
and  even  fatal  forms  may  he  met  with.  The  anemia  may  start  as  a 
simple  anemia  and  later  take  on  a  pernicious  character. 

Etiology. — Simple  anemia  Is  exceedingly  common  in  infancy  and 
childhood.  Owing  to  the  demands  on  the  organism,  anything  which 
interferes  with  the  proper  nutrition  is  liable  to  cause  anemia.  Disease 
or  excessive  weakness  of  the  mother  during  pregnancy  may  be  the  cause 
of  a  weak  child  which  soon  becomes  anemic,  due  to  lack  of  power  to 
form  sufficient  blood.  Children  who  have  insufficient  food,  light,  and 
air  are  always  anemic.  Hemorrhage  in  infancy  and  childhood  may  be 
followed  by  severe  anemia.  The  very  young  are  much  more  affected 
by  hemorrhage  than  are  adults.  The  administration  of  certain  drugs 
may  cause  anemia,  among  them  mercury  and  chlorate  of  potassium  are 
in  common  use.    Anemia  may  follow  almost  any  disease. 

It  may  be  due  to  toxins  which  are  produced  in  the  body,  or  it  may 
be  owing  to  the  fever,  to  malarial  or  other  parasites. 

Classification. — There  have  been  numerous  attempts  to  classify  the 
secondary  anemias.  As  yet  all  classifications  are  arbitrary  and  do  not 
seem  worth  while.  The  presence  or  absence  of  an  enlarged  spleen,  of 
leukocytosis,  and  of  the  severity  of  the  disease  are  the  usual  basis  for 
the  division. 

Pathology. — The  blood  condition  differs  with  the  severity  of  the 
disease.  The  tlifferences  seem  to  be  one  of  degree,  but  it  should  be  borne 
in  mind  that  in  infancy  any  severe  anemia  tends  to  bring  the  blood  back 
nearer  to  the  embryonic  type  or  to  the  type  of  a  younger  child. 

The  hemoglobin  is  lowered;  in  severe  cases  it  may  go  to  .30  or  under. 
The  specific  gravity  is  also  lowered.  The  red  blood  cells  are  tliminished 
in  number,  varying  from  normal  to  1,.5()0,()()()  or  even  lower  than  that. 
There  is  poikilocytosis  and  some  difference  in  size  of  the  cells.  The 
cells  are  usually  undersized  (microcytes),  but  megalocytes  may  be  met 
\\ith.  There  may  be  polychromasia  in  severe  forms.  Nucleated  red 
blood  cells  are  seen  in  varying  numbers.  Normoblasts  are  present  in 
the  average  cases  and  megaloblasts  may  be  seen  in  the  severe  cases. 
There  may  or  may  not  be  leidcocytosls.  This  has  been  considered  under 
that  heading.  There  is  more  likelihood  of  leukocytosis  with  secondary 
anemia  in  infancy  and  childhood  than  in  adult  life,  and  the  number  of 
red  cells  is  usually  much  lower.     (See  Plate  XXIII.) 

Symptomatology. — The  symptoms  vary  with  the  intensity  of  the 
disease.     In  the  mijder  cases  there  Is  pallor  of  the  skin  and  mucous 


PLATE  XXIII. 


cs.^ 


0£l 


^e 


01  O^o 


0 


Blood  from  Case  of  Secondary  Anemia.     (Musser. 

3  and  6.   Lymphocytes. 
4.    Nucleated  P^ed  Blood  Corimscle. 
5.    Pdlynuclear  Leukocytes. 
)c.  4,  r,l,.  1  ,.j  iinmersion.)      Drawn  by  J.  D.  Z    Chase. 


1.  Poikilocytes 

2.  Macrocytes. 


DISEASES  OF  THE  BLOOD  817 

membranes,  languor,  loss  of  appetite  and,  as  a  rule,  some  digestive 
derangement.  In  infants  and  children  there  may  be  marked  irritability 
and  peevishness.  This  in  a  previously  good-natured  child  is  very 
suggestive. 

In  the  severe  cases  the  pallor  is  extreme  and  if  it  is  a  case  of  long 
standing  there  may  be  a  slight  yellowish  tint  in  the  skin.  There  may 
be  slight  edema.  The  tongue  is  usually  coated,  the  appetite  lost,  the 
digestion  poor,  and  either  constipation  or  diarrhea  is  liable  to  be  present. 
The  circulation  is  poor.  If  old  enough  the  child  complains  of  being 
cold  on  the  slightest  exposure.  The  hands  and  feet  feel  cold.  The  heart 
sounds  are  v^eak,  and  there  may  be  a  dilated  heart  with  numerous 
murmurs,  and  an  enlargement  of  the  area  of  dulness.  Of  greater 
frequency  are  hemic  murmurs  heard  over  the  base  of  the  heart  and 
over  the  veins  in  the  neck.  The  respiration  is  more  rapid  than  in 
health  and  breathlessness  results  from  slight  exertion.  These  children 
tire  easily  from  any  effort.  The  patients  are  irritable  and  capricious; 
headaches  are  frequent,  and  indefinite  pains  are  complained  of.  The 
sleep  is  poor  and  the  patient  may  be  very  wakeful.  There  are  liable  to 
be  attacks  of  fainting.  Enuresis  may  be  seen,  which  usually  disappears 
when  the  child  regains  its  health.  Emaciation  is  the  rule,  but  some 
patients  do  not  grow  thin.  Anemic  children  catch  cold  easily  and  are 
prone  to  catarrhal  conditions  of  all  kinds.  There  may  be  hemorrhages 
from  the  nose  or  other  mucous  membranes. 

The  spleen  is  enlarged  in  some  cases,  especially  where  the  predisposing 
disease  is  usually  accompanied  by  an  enlarged  spleen.  The  liver  may 
also  be  enlarged. 

Diagnosis. — This  is,  as  a  rule,  easy.  The  blood  changes  and  the 
existence  of  the  cause  are  sufficient.  If  very  severe  with  megalocytes, 
megaloblasts,  and  polychromasia  it  may  be  impossible  to  distinguish 
simple  or  secondary  anemia  from  the  primary  or  pernicious  form,  unless 
the  history  of  the  case  is  known. 

If  the  spleen  is  enlarged  and  leukocytosis  present  it  may  bring  to 
mind  lymphatic  leukemia  or  the  pseudoleukemia  of  infants.  The 
resemblance  may  be  striking  in  either  instance.  One  should  not  be  too 
hasty  in  coming  to  a  conclusion  in  the  former  case  if  there  is  the  history 
of  one  of  the  causes  of  lymphatic  leukemia.  The  leukemia  is  progressive, 
while  the  anemia  is  apt  to  be  temporary  and  to  improve. 

In  pseudoleukemia  (see  p.  824)  the  spleen  is  usually  larger  and 
myelocytes  are  found  in  considerable  numbers. 

Prognosis.— Prognosis  depends  on  the  cause.  If  it  can  be  ascertained 
and  removed  and  the  blood  condition  is  neither  very  severe  nor  of  long 
duration  the  outlook  is  good.  If  the  anemia  is  severe  the  prognosis  must 
be  guarded.  Monti  states  that  the  cases  with  leukocytosis  are  more 
liable  to  develop  into  severe  anemias  than  those  without  it. 

If  the  hemoglobin  is  reduced  to  below  thirty  or  the  red  blood  cells 
to  2,000,000  or  nearly  that,  the  case  may  be  regarded  as  very  severe. 
The  same  applies  to  the  presence  of  many  megalocytes,  megaloblasts, 
or  to  much  polychromasia.    A  high  color  index  is  also  a  bad  sign. 
52 


818    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

Pernicious  Anemia. — Biermer  called  progressive  pernicious  anemia 
those  cases  where  there  was  no  assij^nahle  cause  and  where  there  was 
a  gradual  progressive  increase  in  the  severity  until  death  took  place. 
We  now  call  pernicious  anemia  those  cases  which  have  a  definite  blood 
T>i(f  lire  which  is  givfn  h<'lf>w.  It  may  rarely  hajjpen  that  a  case  recovers. 
Jn  children  prohahly  three-fourths  of  the  cases  have  either  an  assignable 
cause  or  they  are  ca.ses  which  have  developed  from  secondary  anemias, 
the  blfjod  y>ir'ture  changing  from  one  to  the  other. 

Etiology.  It  is  rare  in  infants  and  children.  Monti  and  Berggrun 
give  H)  cases.  Of  these  2  occurred  in  sucklings,  h  from  one  to  five  years, 
and  0  in  children  over  five  years.  In  4  of  these  cases  there  was  an 
assignable  cause.  Monti  has  stated  that  the  severe  secondary  anemias 
of  child hoofl  with  leukocytr^sis  are  liable  tf>  become  pernicious.  Cases  of 
hereditary  syphilis  and  (jf  rickets  where  there  is  an  enlarged  spleen  are 
i)ut  d(;wn  as  among  the  most  fref|uent  caus(;s.  Intestinal  [>arasites, 
<vsp«-cially  the  ankylostf>ma  diiodenale,  may  be  res[>onsible  ff>r  it. 

Pathology. — The;  lesions  found  consist  in  severe  anemia  of  all  the 
organs,  with  r-xt^-nsive  fatty  degeneration  of  most  of  them.  The  heart 
and  vessels  suffer  most  from  this,  but  the  liver  and  kidneys  are  also 
affected.  There  are  numerous  small  hemfjrrhages.  There  are  deposits 
of  iron  found  in  the  liver,  due;,  according  to  Ilimter,  to  the  destruction 
of  red  blood  cells  in  the;  liver  by  toxins.  These  toxins  in  some  cases  are 
supj)osed  U)  come  from  the  intestinal  canal.  The  lyri)[)h  nodes  are 
oft<'n  a  dark-red  color.  Small  h(;morrliages  an;  usually  found  in  the 
various  f)rgaris. 

The  hhxxl.  changes  an;  charactx-ristic.  The  specific  gravity  is  lowered. 
The  hemoglobin  is  reduced  to  40,  ?i(),  20  or  even  below  that.  The 
hemoglobin  contents  of  each  cell  niay,  however,  be  normal  or  above 
normal.  'J'he  color  index  of  the  cell  is  high.  The  red  blofxl  cells  are 
gr(!atly  n^duced  in  ninnber.  There  may  be  only  2,000,000  per  c.nuri., 
or  vwn  fewer  than  that.  Owing  to  the  high  color  index  they  slain 
well,  but  the  coloring  mattxT  is  usually  taken  uncfjiially.  The  average 
diaineter  of  the  red  blood  cells  is  inereasetl.  Megaloeyles  are  common, 
while  mierocytes  are  rare.  There  is  marked  j»oikiloey(osis.  The  red 
cells  may  be  polychromatf)j)hili(;.  Nucleated  vvi\  blood  cells  are  seen, 
both  nonrioblasts  and  irK-galoblasts.  The  lailer  usually  |)repot)derate. 
Myelocytes  niay  be  seen  occasionally.  The  red  blood  cells  have  lost 
their  tendency  to  ff»rm  ronleanx.  The  leukocytes  are  diminished  at  the 
expense  of  th(;  polynuclear  neulrophiles,  which  gives  a  relative  increase; 
in  the  lymphocytes.  I/'ukocytxjsis  du(!  to  intercurrent  affections  may 
occasionally  complicate  the  picture.      (See  I'lat(!  XXIV.) 

Symptomatology.  The  symj)toms  are  those  of  severe  anemia.  Then; 
is  a  waxy  pallor  of  the  skin  and  irmcous  nieird)ranes.  The  skin  usually 
is  a  light  lemon  tint.  There  may  Im;  slight  puffiness  or  edema,  and  lat<! 
in  the  disease  this  may  be  very  marked  and  there  iriay  Ik;  effusiotis  into 
the  serous  cavities.  There  may  or  may  not  be  emaciation.  If  there 
is  no  emaciation  the  extreme  pallor  with  the  ap|)arently  well-nourished 
appearance   ia  almost  in   itself  diagnostic,     'j'here   is  great  wcakiK^ss 


{ 


DISEASES  OF  THE  BLOOD  S19 

amounting,  sooner  or  later,  to  prostration.  There  are  restlessness,  dis- 
turbed sleep,  and  nervousness.  In  some  there  may  be  pain  in  the  extrem- 
ities. There  is  marked  dyspnea  on  exertion.  The  heart  is  likely  to 
become  dilated  and  is  constantly  found  enlarged.  Hemic  murmurs  and 
those  due  to  the  dilatation  are  present.  There  is  a  venous  hum  over 
the  larger  vessels.  There  are  digestive  disturbances.  As  the  disease 
progresses  there  are  hemorrhages  from  the  mucous  membranes  and 
under  the  skin.  The  urine  is  small  in  amount,  of  low  specific  gravity, 
and  contains  no  albumin.  As  a  rule,  there  are  no  appreciable  clinical 
changes  iii  the  liver,  spleen,  or  lymph  nodes. 

Diagnosis. — This  may  be  difficult  at  the  start  or  under  certain  con- 
ditions, and  impossible  without  a  blootl  examination.  Although  the 
general  clinical  picture  of  a  severe  anemia  is  sufficiently  clear,  yet  the 
prognosis  depends  often  on  the  nature  of  the  blood  change.  This  is 
particularly  true  of  a  child  where  an  anemia  may  be  very  severe  as 
far  as  general  symptoms  go,  but  which  still  shows  the  characteris- 
tics of  a  secoutlary  anemia.  If  the  cause  can  be  removed  and  the  child 
managed  properly  recovery  may  be  rapid.  If  the  blood  change  is  that 
of  pernicious  anemia,  however,  the  outlook  is  bad. 

Eosinophilia  in  a  severe  anemia  may  point  out  a  cause,  as  it  is  seen 
when  there  are  intestinal  parasites.  These  should  be  looked  for  in  all 
cases  and  especially  when  the  eosiuophiles  are  increased. 

From  other  blood  conditions  the  diagnostic  points  are  as  follows: 
Severe  chlorosis  may  clinically  suggx^st  pernicious  anemia  owing  to  the 
wcU-ncuu-ished  condition,  the  tinting  of  the  skin,  and  the  strildng  pallor. 
The  number  of  red  blood  cells  is  rarely  anything  like  as  low  in  chlorosis, 
in  which,  as  a  rule,  it  is  not  far  from  normal.  I'he  color  index  of  the 
cells  is  very  different.  In  chlorosis  it  is  low.  Many  of  the  cells  look 
like  colorless  shadows.  In  pernicious  anemia  it  is  high  and  the  cells 
arc  dark.  They  are  also  liable  to  be  larger.  Megaloblasts  have  been 
notetl  in  chlorosis,  but  are  never  a  feature  of  the  disease. 

In  .srcoudanj  anemia  the  number  of  red  blood  cells  is  not  so  low,  as 
a  rule.  There  may  be  a  leukocytosis  from  the  original  cause.  The 
color  index  of  the  red  cells,  their  increased  size,  and  the  presence  of 
megaloblasts  in  abundance  are  the  greatest  helps. 

In  leukemia  the  diagnosis  may  not  be  as  easy  as  it  would  seem,  espe- 
cially in  infancy,  where  there  may  be  a  leukoc-ytosis  and  an  enlarged 
spleen  in  any  anemia.  The  red  cells  are  more  liable  to  be  reduced  from 
leukemia  in  infants.  The  large  number  of  myelocytes  in  the  leukemic 
blood  is  the  most  distinguishing  feature. 

The  pseudoleukemia  of  infants  (von  Jakseh)  is  discussed  under  that 
disease  (p.  822). 

Prognosis. — The  course  of  the  disease  is  progressively  downward,  but 
there  are  remissions  where  the  blood  state  and  the  general  condition 
may  improve.  There  may  be  fever  with  the  exacerbations.  The 
average  case  is  more  rapid"  in  the  child  than  in  adults  and  the  height 
of  the  disease  is  reached  in  six  or  eight  weeks.  The  disease  usually 
lasts  several  months  before  death  takes  place.     Very  rarely  it  may 


820    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

persist  longer  and  a  few  cases  have  been  rejjorted  where  recovery  took 
place. 

In  all  cases  the  outlook  is  batl,  but  in  a  general  way  what  may  be 
called  the  more  favorable  cases  can  be  told  by  the  presence  of  a  large 
number  of  normol)lasts.  The  presence  of  a  large  number  of  megalo- 
bhusts  is  regarded  as  extremely  unfavoral)le.  (/abot  has  arranged  what 
may  be  regarded   as   favorable   and   unfavorable   blood  conditions  as 

follows : 

Severe  (Rapidly  Fatal).— (a)  extreme  progressive  anemia;  (/>)  high 
color  index;  (c)  increase  in  size  of  red  cells;  {d)  degenerative  changes; 
(c)  numerous  megaloblasts ;  (/)  few  or  no  normoblasts;  (</)  lymphocytosis. 

Less  Severe  (Slower  Course).— (a)  remissions;  {b)  normal  or  low 
color  index;  (c)  normal  size  or  small  cells;  (d)  no  degenerative  changes; 
(e)  numerous  normoblasts;  (/)  few  megaloblasts;  (g)  normal  percentage 
of  p()lym()r])honuclear  ct>lls. 

Treatment. — Treatment  of  pernicious  anemia  is  discussed  on  p.  827. 


CHLOROSIS. 

Chlorosis  Is  a  primary  anemia  in  whieii  there  is  a  lowering  of  the 
hemoglobin  without  any  marked  diminution  of  the  number  of  the  red 
blood  cells,  except  in  very  severe  cases.  It  occurs  most  frequently  about 
pulierty  and  there  is  a  characteristic  greenish-yellow  color  imparted  to 
the  skin  which  has  led  to  th?  popular  name  of  "green  sickness." 

Etiology. — The  exact  cause  is  unknown.  It  occurs  about  puberty, 
as  a  rule,  and  is  almost  always  seen  in  girls.  Occasional  cases,  however, 
mav  be  seen  in  boys.  It  is  more  frequent  in  brunettes  than  in  blondes. 
Previous  ill  health  and  more  especially  bad  hygiene  are  ])redisposing 
causes.  The  majority  of  the  cases  are  seen  in  girls  who  have  a  lack 
of  fresh  air,  sunshine  and  light,  of  exercise  in  the  open  air,  and  also  of 
proper  food.  Overcrowding  and  overwork  make  it  common  among 
factory  and  shop  girls.  Marked  psychical  disturbance  is  also  a  factor. 
Virchow  put  down  as  a  cause  the  congenital  narrowness  of  the  aorta 
and  l)loodvessels  and  a  small-sized  heart.  This  could  hardly  be  true, 
as  most  cases  recover  perfectly.  These  changes  are,  however,  found 
in  the  status  lymphaticus,  in  which  there  is  frequently  a  chlorotic  con- 
dition of  the  blood. 

Pathology. — Cases  rarely  come  to  autopsy.  Those  that  do  have 
usually  died  of  a  complicating  tuberculosis,  ulcer  of  the  stomach,  or  of 
some  other  intercurrent  affection.  The  right  ventricle  is  usually  dilated 
and  the  left  hypertrophied. 

The  blood  condition  is  very  characteristic.  The  hemoglobin  is  very 
low,  twenty,  thirty,  or  forty  being  common  finds  according  to  the 
customary  von  Fleischl  scale.  In  very  severe  cases  it  may  go  even  below 
that.  The  blood  as  drawn  seems  almost  colorless  in  these  very  severe 
cases.  The  specific  gravity  is  lowered.  The  red  blood  cells  are  normal 
in  number  or  nearly  so  in  the  average  case.     It  must  be  borne  in  mind 


PLATE  XXIV. 


FICt,    h, 


«^ 


Q 


Si 


^EiA 


o 


.%>> 


■4^- 


Blood  from  Case  of  Chlorosis,  showing  Slight  Staining 
of  the  Red  Blood  Corpuscles  and  Presence  of  Mononuclear 
Leukocytes.     fMusser. ) 

(Oc.  4,  ob.  i/i2  immersion.)     Prawn  by  .T.  T>.  Z.  Chase. 


Fia.  2. 


Pernicious  Anemia.     (Musser. ) 

1.  Large  Mononuclear  Lymphocyte.  5.    Small  Lymphocyte. 

2.  Polymorphonuclear  Leukocyte  or  Neutrophile.        0.   Poikilocyte. 

3.  Mesaloblast  1  t,,-     ,  ,  t,    ,  ^ 

4     M"  "     hi   st      >   ^"'■'ss^^^^l  "''^l  Corpuscles.  7.    Normal  Red  Cnrpusclr 


DISEASES  OF  THE  BLOOD  821 

that  in  severe  cases  the  number  of  red  cells  may  fall  to  two  or  three 
million  per  cubic  millimetre.  The  color  index  of  the  cell  is,  however, 
lowered.  The  size  and  shape  of  the  cell  are  altered  and  these  are  more 
marked  in  the  severe  than  in  the  mild  cases.  Some  of  the  cells  may 
have  so  little  hemoglobin  as  to  look  like  faint  round  shadows.  Other 
cells  are  somewhat  smaller  than  normal  and  there  may  be  poikilo- 
cytosis.  Normoblasts  may  be  seen  sometimes  in  the  severe  cases.  The 
leukocytes  are,  as  a  rule,  normal,  but  there  may  occasionally  be  a  slight 
leukocytosis.    (See  Plate  XXIV.) 

Symptomatology. — The  symptoms  are  much  like  those  of  a  simple 
anemia,  but  there  is  no  emaciation,  the  well-nourished  appearance 
being  in  striking  contrast  to  the  pallor  and  tint  of  the  skin.  The  skin 
has  a  greenish-yellow  color  and  there  may  be  patches  of  darker  pigmen- 
tation. There  is  frequently  slight  puffiness  or  edema  present.  There  is 
shortness  of  breath  on  exertion.  Palpitation  of  the  heart  is  common 
and  there  is  a  rapid,  weak  pulse.  The  heart  is  often  dilated  if  there 
has  been  much  severe  exertion.  This  is  usually  seen  in  the  right  ventricle, 
but  the  left  may  also  be  affected.  There  may  be  some  hypertrophy  of 
the  left  ventricle.  Hemic  murmurs  are  heard  over  the  base  of  the  heart 
and  a  venous  hum  over  the  large  vessels  in  the  neck.  There  is  a  coated 
tongue,  a  capricious  appetite,  and  unusual  longings  for  all  sorts  of 
strange  articles  of  diet.  After  eating  there  is  often  discomfort  or  indi- 
gestion. Pain  in  the  region  of  the  stomach  is  a  frequent  complaint. 
Hyperacidity  may  be  present  and  gastric  ulcer  may  complicate  the 
case.  Constipation  is  the  rule.  There  is  generally  amenorrhea  in  older 
girls.  Slight  albuminuria  may  be  present.  There  may  sometimes  be 
a  little  fever. 

The  patient  is  nervous,  fretful,  and  irritable.  Attacks  of  crying  from 
slight  causes  are  not  uncommon.  There  may  be  hysterical  attacks. 
Vertigo  is  of  frequent  occurrence  and,  if  not  that,  the  patient  complains 
of  attacks  of  faintness. 

The  duration  is  that  of  a  chronic  condition.  The  cases  last  months 
or  even  a  year  or  more.  The  course  varies.  There  may  be  periods 
where  the  condition  is  reasonably  good  followed  by  relapses. 

Diagnosis. — Diagnosis  is  easy.  The  disease  can  usually  be  recognized, 
at  a  glance.  The  blood  examination  settles  the  question.  Care  should 
be  taken  to  recognize  those  cases  associated  with  the  status  lymphaticus. 

Prognosis. — This  is  good  if  there  are  no  complicating  diseases. 

Treatment. — Prophylaxis  is  important.  Shop,  factory,  and  school-girls 
should  have  sufficient  fresh  air  and  light  and  not  be  overcrowded.  A 
few  factories  have  recognized  that  they  can  save  money  by  arranging 
for  the  health  and  well-being  of  their  employes.  The  medicinal  treat- 
ment is  alonff  the  same  lines  as  for  other  cases  of  anemia.  Diet  is 
important  and  iron  the  most  efficient  drug. 


822    1>ISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 


PSEUDOLEUKEMIA  OF  INFANTS  (VON  JAKSCH). 

The  disease  described  by  von  Jaksch,  in  1SS9,  as  Anemia  Infantum 
Ps(nul()l«Mik('mica  is  a  rare  form  of  anemia  s(>en  only  in  infants.  It  is 
characterized  by  a  grave  anemia  and  leukocytosis,  too;ither  with 
enlart^ement  of  the  spleen,  liver,  and  sometimes  of  the  lymph  nodes. 
There  has  Ikx'U  much  discussion  as  to  wlu>thi>r  the  condition  is  really 
a  separate  disease,  and,  if  it  Is  not,  whetlu  r  it  should  be  classed  as  a 
secondarv  anemia,  as  a  pernicious  anemia,  or  as  a  leukemia,  ^\ithout 
entering  into  the  discussion  it  may  be  said  that  it  is,  for  the  present  at 
any  rate,  a  good  way  to  dispose  of  a  certain  number  of  puzzling  anemias 
of  early  life. 

Etiology. — The  majority  of  cases  occur  between  seven  and  twelve 
months  of  age.  It  has  been  seen  somewhat  ( arli(>r  and  also  as  late  as 
three  and  four  years. 

In  twenty  cases  collected  by  Monti  and  Berggriin,  sixteen  had 
rickets  and  one  hereditary  sj-philis.  Monti  is  of  the  opinion  that  it  may 
develop  from  severe  anemias. 

Pathology. — The  spleen  is  large  and  han!.  There  may  be  thickening 
of  the  c:ii)sule;  microscopically  the  only  change  Is  a  sim])le  hyper- 
plasia. The  liver  is  enlarged  in  almost  half  the  cases  and  is  said  to  bear 
no  relation  to  the  size  of  the  spleen.  Th(>re  Is  no  infiltration  of  the  liver 
with  white  cells  as  in  leukemia,  but  there  are  some  red  and  white  cells 
found.  In  about  half  the  cases  there  has  been  enlargement  of  the  lymph 
nodes.     Changes  in  the  bone-marrow  have  been  noted. 

The  blood  condition  Is  as  follows:  The  specific  gravity  is  lowered 
from  1.035  to  1.045.  The  hemoglobin  is  lowered,  in  some  as  much  as 
to  .30.  The  red  blood  cells  are  greatly  diminished  sometimes  to  lens 
than  a  million,  usually  to  between  one  and  two  millions.  The  red  cells 
are  frequently  changed  both  in  size  and  shape.  There  are  microcytes 
and  megalocytes  as  well  as  poikilocytosls.  Nucleated  red  cells  are 
present,  both  normoblasts  and  megaloblasts.  The  white  cells  are 
increased  so  that  the  relation  of  white  to  red  cells  is  below  1 :  100.  Monti 
gives  the  variations  as  between  1  :S5  to  1 :  15.  In  other  words,  a  leuko- 
cytosis of  from  20,000  to  50,000.  The  mononuclears  and  polynuclears 
are  both  increased,  sometimes  one  and  sometimes  the  other,  "^riie 
eosinophiles  may  be  increased.  jNIyelocytes  may  be  present.  The  white 
cells  stain  differently  and  there  may  be  curious  appearances  caused  by 
the  irregular  way  in  which  they  react  to  the  ordinary  dyes. 

Symptomatology.— The  symptoms  of  the  disease  are  those  of  a  chronic 
anemia.  There  Is  usually,  though  not  always,  emaciation.  The  severe 
anemia  causes  a  cachectic  appearance.  There  Is  loss  of  appetite  and 
digestive  dlsturl)ance.  The  spleen  is  large.  The  liver  and  lymph  nodes 
may  also  be  enlarged.  The  disease  may  go  to  a  certain  point  and  then 
remain  at  a  standstill.  There  may  be  periods  of  improvement  and 
periods  where  the  patient  grows  worse.  After  dragging  along  for  a 
long  time  the  patient  may  die,  sometimes  apparently  from  the  anemia, 


DISEASES  OF  THE  BLOOD  g23 

sometimes  from  some  intercurrent  disease.  Four  cases  out  of  jMonti 
and  Burggriin's  twenty  died. 

Diagnosis. — This  may  be  a  matter  of  considerable  difficulty.  It  is 
on  searching  and  weighing  the  differential  points  that  one  realizes  on 
what  an  insecure  basis  the  disease  really  stands.  The  symptom-complex 
with  the  blood  findings  taken  all  together  are  of  the  greatest  value. 
Monti  regards  it  as  a  sort  of  forerunner  of  leukemia  in  some  cases.  If 
the  patient  dies  the  autopsy  shows  a  different  process  from  leukemia. 
If  the  patient  recovers  it  is  good  evidence  that  it  was  not  leukemia. 
The  leukocytes  are  not  so  numerous  as  in  leukemia,  but  it  must  be 
borne  in  mind  that  under  certain  conditions  a  low  leukocyte  count  may 
be  found  in  leukemia.  The  percentage  of  myelocytes  is  lower  in  pseudo- 
leukemia, as  a  rule.  The  liver  is  not  so  large  and  the  Ipiiph  nodes 
may  not  be  enlarged  at  all  in  some  cases. 

The  color  index  is  lower  in  pseudoleukemia  as  a  general  thing  than 
in  pernicious  anemia.  The  number  of  red  cells  is  lower  in  pernicious 
anemia.  It  must  be  borne  in  mind  that  leukocytosis  may  occur  in  any 
grave  anemia  in  infancy;  were  it  not  for  this  the  diagnosis  would  be  easy. 
The  general  clinical  picture  with  the  larger  number  of  myelocytes  is 
the  best  means  of  distinguishing  the  two. 

The  fact  that  rickets  and  SA'philis  may  both  cause  anemia  and  leuko- 
cytosis with  enlarged  spleen,  liver  and  lymph  nodes  makes  it  difficult 
to  separate  secondary  anemia  at  times  from  pseudoleukemia.  The 
spleen  is  perhaps  larger  in  the  latter  and  myelocytes  more  in  evidence. 
When  there  has  been  neither  rickets  nor  s)^hilis  the  diagnosis  is 
easier. 

The  nodes  are  larger  in  Hodgkin's  disease  and  the  anemia  is  not  so 
severe.  Should  there  be  any  doubt  a  section  of  the  nodes  will  clear 
up  the  diagnosis. 

Treatment. — Tliis  is  the  same  as  outlined  for  anemia  (p.  827). 


LEUKEMIA. 

This  is  a  condition  where  the  white  blood  cells  are  principally  affected. 
Ehrlich  has  spoken  of  it  as  a  "mixed  leukocytosis"  where  all  forms  of 
white  cells  were  increased  as  in  contradistinction  to  polynuclear  leuko- 
cytosis either  of  the  neutrophilic  or  the  eosinophilic  t}^e.  There  are 
in  addition,  in  one  of  the  forms,  cells  which  normally  belong  in  the  bone- 
marrow — myelocytes.  With  these  blood  changes  there  are  lesions  in 
the  spleen,  bone-marrow,  and  in  some  cases  in  the  lymph  nodes.  In 
infants  it  may  at  times  be  difficult  to  draw  the  line  in  some  cases  of 
leukocytosis  and  leukemia,  especially  of  the  lymphatic  type. 

Etiology. — Etiology  is  obscure.  It  is  rare  in  infancy  and  childhood, 
but  is  occasionally  seen.  In  some  cases  there  seems  to  be  an  hereditary 
influence.  It  is  more  common  in  boys  than  in  girls.  Some  of  the  cases 
are  distinctly  primary,  no  previous  disease  having  been  noted.  In 
others   congenital   s}^hilis,   rickets,   malaria,   simple   anemia   and   the 


824    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

various  infections  of  childhood  have  been  observed  as  precedinj^  it.  In 
some  instances  tlie  child  has  had  a  succession  of  the  diseases  incident 
to  early  life  and  it  Ls  impossible  to  say  \vheth(>r  there  is  any  connection 
between  the  two  or  not. 

There  arc  numerous  theories  regardinti;  the  cause  of  the  disease.  By 
many  it  has  been  regarded  as  an  infection.  Lowit  claims  to  have  found 
a  hemameba  in  the  blood  of  leukemic  patients  which  he  regards  as  the 
cause.     This  needs  confirmation. 

Pathology. — There  are  two  types  of  the  disease.  The  commonest 
form,wlu're  the  principal  changes  are  in  the  spleen  and  bone-marrow,  is 
called  splmomi/clogcuow'i  or  myelogenous  leukemia.  The  other  form 
is  the  h/mphaii'r,  where  the  lymph  nodes  are  the  principal  site  of  disease. 
All  the  organs  mentioned  are  involved  in  some  cases. 

The  lesions  found  are  very  striking.  'I'he  blood  in  very  severe  cases 
contains  so  many  white  cells  as  to  approach  pus  in  its  appearance. 
The  bone-marrow  is  the  seat  of  extensive  changes,  consisting  principally 
in  the  infiltration  with  lymphoid  cells,  which  in  some  cases  give  it  a 
greenish-yellow  aj^pearance.  The  spleen  is  enlarged.  Usually  the 
enlargement  is  very  great,  as  it  may  take  up  over  half  of  the  abdominal 
cavity.  In  the  more  acute  cases  it  is  found  to  be  soft,  dark,  and  full  of 
blood.  Later  it  becomes  harder  and  there  may  be  perisplenitis.  The 
organ  is  full  of  nodules  which  are  made  up  of  lymphoid  cells.  The 
Mal]Mghian  corpuscles  are  prominent  and  microscopically  there  is 
found  to  be  a  superabundance  of  lymphoid  cells.  There  may  be  infarc- 
tions. The  liver  Is  enlarged  and  may  contain  lymphomatous  nodules. 
In  the  lymphatic  form  the  lymph  nodes  are  enlarged  and  hard,  but  are 
usually  movable.  At  the  outset  one  or  more  groups  may  be  affected, 
but  later  on  there  is  liable  to  be  a  general  enlai'gement  of  all  of  the 
nodes.  The  lymphoid  tissue  in  the  intestinal  tract  may  be  affected  and 
also  the  tonsils  and  the  lymphoid  tissue  about  the  mouth. 

There  are  two  types  of  lymphatic  leukemia.  In  the  acute  there  is 
only  moderate  enlargement  of  the  spleen  and  a  great  tendency  to  petechia 
and  to  hemorrhages.  This  has  been  regarded  as  an  infection.  In  the 
chronic  t^'pe  the  spleen  is  very  large. 

The  two  forms,  lymphatic  and  splenomyelogenous,  get  their  differ- 
entiation chiefly  from  the  blood  changes.  The  hemoglobin  is  diminished. 
The  red  blood  cells  are  usually  diminished  but  normal  in  size  except  in 
very  severe  cases.    There  are  normoblasts  present. 

In  the  splenomijelogenous  form  the  white  cells  are  enormously 
increased.  The  mnnber  may  be  as  high  as  500,000,  while  100,000 
is  a  common  number.  These  consist  of  large  numbers  of  myelocytes 
of  various  sizes.  The  polynuclear  neutrophiles  are  increased,  but  the 
percentage  of  them  present  may  be  decreasefl.  The  lymphocytes  vary 
a  great  deal.  They  are  increased  more  in  some  cases  than  in  others. 
The  large  mononuclears  are  increased.  The  polynuclear  eosinophiles 
are  increased  and  this  may  be  a  point  of  some  diagnostic  importance, 
though  it  is  not  one  of  the  especially  characteristic  features  of  the 
disease.    The  mononuclear  eosinophiles  are  also  increased.      The  mast 


PLATE  XXV. 


FIO.    1. 


Lymphatic  Leukemia.     (Musser. ) 

1.    Larare  Mi>n. niuflear  I.ymphocyte.  2.    Polymorphonuclear  Leukocyte  or  Xeutrophile. 

3.    Small  L\minhocyte.  di\nrlina;  Nuclei. 


^doo  #^^  Co  qM 


Splenonayelogenous  Leukemia.     (Musser.) 

1.  Myelocyte.    2.  Eosinophile  Myelocyte.    H.  XortQobla.stic  Red  Corpuscles;  dividing  or  fragmenring  nuclei. 

4.    Eo.sinophile  Leukocyre  ?Iononuclear  Lymphocyte,     fi.   Small  Lymphocyte. 

7.   Polymorph  .kocyte  or  Xeutrophile.      S.    Megaloblast. 


DISEASES  OF  THE  BLOOD  825 

cells  may  be  very  much  increased,  which  is  of  considerable  importance 
in  diagnosis. 

.  In  the  lymphatic  form  the  lymphoid  cells  are  the  features  of  the 
disease.  They  may  form  as  high  as  SO  or  90  per  cent,  of  all  white  cells 
present.  The  other  white  cells  may  be  increased  as  far  as  actual  numbers 
go,  but  they  are  diminished  when  it  comes  to  estimating  percentages 
by  differential  counting.  In  some  cases  the  blood  may  seem  to  consist 
almost  entirely  of  lymphocytes  and  red  blood  cells.  Myelocytes  and 
mast  cells  may  or  may  not  be  present.     (See  Plate  XXV.) 

Two  things  must  be  borne  in  mind.  One  is  that  just  before  death 
the  white  cells  may  fall  to  normal  or  below  it  and,  secondly,  there  may 
be  a  return  to  the  normal  or  near  it  when  there  is  some  intercurrent 
infection,  as  typhoid  fever.  After  this  has  disappeared  the  leukemic 
condition  of  the  blood  returns. 

Symptomatology. — The  disease  in  infants  and  children  is  essentially 
the  same  as  that  seen  in  adult  Hfe,  but  it  is  more  rapid  in  its  course, 
as  a  rule,  and  it  has  been  described  as  having  the  symptoms  more 
exaggerated.  The  course  of  the  disease  is  a  matter  of  weeks  or  of 
months.  The  course  may  be  very  acute,  and  an  instance  is  recorded 
where  in  a  typical  case  death  took  place  ten  days  after  the  onset  in  a 
previously  healthy  infant.  On  the  other  hand,  it  may  drag  on  for  a 
year  or  more.    There  is  a  case  on  record  that  lasted  three  years. 

The  onset  may  be  sudden,  but  is  usually  very  insidious.  Sometimes 
a  sudden  hemorrhage  calls  attention  to  the  disease  which  had  been 
given  no  especial  concern  before.  Ordinarily  there  is  the  gradually 
increasing  pallor  of  the  skin  and  mucous  membranes.  There  is  some 
digestive  disturbance  which  is  often  thought  to  be  the  only  trouble. 
There  are  loss  of  appetite,  indigestion,  attacks  of  vomiting  or  of  diarrhea 
and  sometimes  a  little  fever.  There  is  a  tendency  to  hemorrhages. 
These  are  usually  slight  in  the  beginning.  Nose-bleed  or  a  little 
bleeding  from  the  gums  or  a  little  blood  in  the  stool  may  be  noted. 
The  skin  bruises  easily  and  slight  blows  and  knocks  which  ordinarily 
would  cause  no  trouble  may  leave  an  ecchymotic  spot.  The  sleep  is 
disturbed  and  the  child  becomes  nervous  and  irritable.  As  the  disease 
progresses  the  spleen  becomes  enlarged  and  the  attention  of  the  mother 
is  usually  called  to  the  enlarged  abdomen  and  the  splenic  tumor.  In 
other  cases  the  enlargement  of  the  lymph  nodes  is  noted. 

The  Developed  Stage. — When  the  disease  has  reached  its  full  stage 
of  development,  if  such  an  expression  may  be  allowed,  the  picture  is 
a  striking  one.  The  pallor  is  extreme.  The  skin  is  flaccid,  has  lost 
its  transparency,  and  is  of  a  dirty,  muddy  appearance.  There  is  a  ten- 
dency to  perspire.  There  may  be  occasionally  a  little  icterus.  There 
is  a  liability  to  eczema  and  sometimes  there  are  pemphigoid  eruptions. 
Purpura  is  common.  The  purpuric  spots  may  be  rather  small  and 
numerous  or  they  may  be  larger  and  resemble  bruises.  Rarely  there 
are  lymphomatous  nodules  in  the  skin.  These  are  small,  whitish  masses, 
varying  in  size  from  the  size  of  a  grain  of  wheat  to  a  centimetre  in 
diameter.     When  seen  they  are  usually  scattered  all  over  the  body. 


826     DISEASE:^  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

As  the  (U.'iea.se  progresses  there  is  more  or  less  edema  and  this  is  most 
notieeal)U'  about  the  face  and  extremities.  Later  on  there  may  be 
effusions  into  the  serous  cavities. 

'  The  enlarged  nodes  which  are  usually  present  make  a  striking  picture. 
There  are  generally  several  groups  a tt'ected,  in  some  cases  practically  all 
the  lymphoid  tissue  of  the  Ixxly  is  involved.  The  cervical  nodes  are 
prol):U)ly  the  most  noticeable  and  tlu«  large  collar  of  nodes  may  interfere 
with  the  movements  of  the  head.  The  axillary  and  inguinal  nodes  are 
also  easily  felt.  They  are  hard  but  not  tender  and  are  movable.  The 
intrathoracic  nodes  mav  be  enlarged  and  produce  pressure  symptoms 
similar  to  those  mentioned  in  Ilodgkin's  disea.se.  The  mesenteric  nodes 
may  be  enlarged  and  easily  palpable.  The  tonsils  and  the  lvm|)li(jid 
tissue  about  the  fauces  and  mouth  may  be  very  much  afl'ected  and  be 
a  noticeable  feature  of  the  disease. 

I'hc  s'plcen  is  enlarged  in  all  cases  that  have  lasted  any  length  of  time. 
When  it  is  large  fissures  may  l)e  felt  along  its  margin.  It  may  extend 
to  the  umbilicus  or  even  farther.  There  may  be  tenderness  over  the 
spleen.  The  abdomen  is  distended  and  the  child  pot-bellied.  The 
liver  is  often  somewhat  enlarged  and  may  be  very  much  so.  The  urine 
earlv  in  the  disease  shows  no  especial  changes,  but  later  there  are 
albumin  and  casts.  The  heart  is  rapid  and  weak.  There  is  dyspnea 
on  the  slightest  exertion  and  there  may  be  cough.  The  digestive 
symptoms  are  constant  and  generally  pronounced,  the  loss  of  appetite 
and  a  tentlency  to  diarrhea  l)eing  most  constant.  There  may  be 
obstinate  constipation;  in  some  cases  there  may  be  hemorrhage  of  the 
bowel.  The  hemorrhagic  tendency  becomes  more  and  more  marked 
and  may  cause  great  w^eakness.  The  hemorrhages  may  occur  from 
anv  mucous  membrane  or  be  subcutaneous. 

There  may  be  disturbance  of  vision  due  to  leukemic  retinitis,  and 
there  may  be  deafness.  Nervous  symptoms  are  usually  noticeable. 
There  is  somnolence  in  some  cases  which  may  deepen  into  coma. 
There  may  be  delirium.  Pain  may  be  complained  of  by  older  children, 
that  in  the  spleen,  the  extremities,  and  head  being  most  marked.  The 
general  weakness  is  extreme  and  there  may  be  attacks  of  fainting. 
There  may  be  fever  ranging  from  101°  to  103°  F.,  with  even  greater 
variations. 

The  clinical  form  of  the  disease  and  the  blood  findings  are  not  so 
marked  as  one  would  expect.  But  few  cases  remain  pure  to  the  end. 
Sooner  or  later  they  become  mixed  cases  and  show  changes  in  nodes 
and  bone-marrow  as  well.  There  may  occasionally  be  noted  causes  of 
acute  lymphatic  leukemia  where  the  lymph  nodes  are  enormously 
enlarged,  while  the  spleen  is  comparatively  small.  In  the  chronic 
lymphatic  cases  the  spleen  is  always  enlarged,  sometimes  enormously 
so.  The  diagnosis  Hes  in  the  blood  examination,  which  should  be  made 
in  all  anemic  cases. 

Prognosis. — Prognosis  is  always  bad.  Cases  of  recovery  have  been 
said  to  occur,  but  need  not  be  looked  for.  Remissions  may  occur  and 
the  patient  seem  better  for  a  time,  but  the  disease  returns. 


DISEASES  OF  THE  BLOOD  827 


TREATMENT  OF  ANEMIA  AND  LEUKEMIA. 

The  treatment  of  all  forms  of  anemia  and  of  leukemia  may  be  con- 
sidered together.  In  all  cases  the  general  management  of  the  child  is 
of  great  importance.  Fresh  air,  sunshine,  rest,  and  in  mild  grades  of 
secondary  anemia,  carefully  regulated  exercises  are  required.  In  all 
severe  anemias  undue  exertion  should  be  avoided,  and  if  there  is  marked 
shortness  of  breath  or  disturbance  of  the  heart  the  child  should  be  kept 
in  bed.  While  in  bed  the  child  should,  if  possible,  be  given  sun-baths  or 
be  in  the  fresh  air.  Porches,  fire-escapes,  and  the  like,  may  be  utilized 
for  this  purpose.     Excitement  of  all  kinds  should  be  avoided. 

The  feeding  in  young  infants  is  important  The  general  rules  for 
infant  feeding  may  be  followed  where  possible.  In  older  children  there 
should  be  five  meals  daily  at  regular  intervals  and  the  amount  should 
be  small  enough  to  permit  of  perfect  digestion.  It  is  a  good  plan  to 
give  plenty  of  proteid  food  at  breakfast — -milk,  eggs,  or  meat.  If  the 
diet  in  general  contains  too  little  proteid,  somatose,  eucasin,  or  some 
similar  preparation  may  be  added.  In  addition  to  meat  and  eggs, 
fresh  fruit  and  vegetables  may  be  used.  Milk  or  mixtures  of  milk  and 
cream  should  be  given  at  the  end  of  the  meal  to  avoid  spoiling  the 
appetite,  as  may  be  done  if  it  is  given  the  first  thing.  In  pernicious 
anemia  Hunter  advises  but  little  proteid  food  and  a  great  deal  of  carbo- 
hydrates and  milk.  Beef-juice,  raw  beef,  glycerin  extract  of  red  bone- 
marrow  may  all  be  given  to  advantage,  and  the  soluble  beef  prepara- 
tions are  of  value  in  some  cases,  especially  when  combined  with  iron. 
Cod-liver  oil  is  useful  vvhen  it  is  well  borne  and  does  not  disturb  the 
appetite.  A  change  of  air  and  climate  is  very  beneficial,  especially  a 
change  to  mountains  or  seashore  for  children  who  have  a  diminution 
of  the  number  of  red  blood  cells.  All  these  children  require  sun- 
light. 

In  secondary  anemia  the  cause  should  be  sought  for  and  removed. 
Intestinal  parasites  should  be  looked  for,  especially  if  there  is  eosin- 
ophilia.  In  pernicious  anemia  the  ankylostoma  or  its  eggs  should  be 
searched  for  in  the  stools.     If  suspectecl,  thymol  should  be  given. 

The  drugs  of  especial  value  are  iron,  arsenic,  and  tonics.  In  chlorosis 
and  secondary  anemia,  iron  is  by  far  the  most  valuable.  If  the  child 
can  swallow  a  pill,  freshly  prepared  Bland's  pills  are  to  be  recommended. 
Aloes  and  nux  vomica  may  be  added  to  prevent  constipation.  Solutions 
of  iron  and  manganese  peptonate  may  be  used  and  are  particularly 
well  borne.  For  young  infants  these  are  the  best  forms.  The  bitter 
wine  of  iron  is  also  of  value.  Arsenic  is  valuable  alone  or  to  alternate 
with  the  iron. 

In  leukemia  and  pernicious  anemia  arsenic  in  the  form  of  Fowler's 
solution  should  be  given  0.06  c.c.  (1  drop)  three  times  a  day,  and  gradu- 
ally increased  to  three,  five,  or  even  more  drops  a  day  according  to  the 
age  of  the  child.  Care  should  be  taken  to  avoid  arsenic  poisoning. 
A  metallic  taste  in  the  mouth  or  puffiness  about  the  eyes  is  an  indication 


82»    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

to  stop  it.     An  arsenical  neuritis  may  bo  the  first  symptom  of  arsenic 

p()is()niii<;.  Iron  is  also  used.  Very  recently  several  remarkable  cases 
of  temporary  return  to  a  normal  blood  state  in  leukemia  following  the 
use  of  Roentgen  rays  have  been  reported.  The  exposure  was  made 
daily  over  the  spleen.  Care  should  be  taken  not  to  burn  the  patient. 
The  explanation  would  seem  to  be  that  the  .r-rays  stop  mitosis,  as  has 
been  proven  experimentally.  The  value  of  this  treatment  is  not  definite, 
but  it  looks  [)romising.  Recently  Holding  and  Warren^  have  re})orted 
success  with  this  method,  especially  in  the  splenic  form  of  leukemia:  8 
of  25  cases  were  said  to  be  cured  and  15  cases  improved.  In  lymphatic 
leukemia  the  results  were  not  so  satisfactory,  but  im])rovement  was  noted. 
The  .T-rays  seem  also  to  have  been  beneficial  in  pseudoleukemia. 

The  pseudoleukemia  of  infants  should  be  treatetl  by  iron  or  arsenic 
and  iron  alternating.  Fowler's  solution  O.OG  c.c.  (1  drop)  three  or  four 
times  a  day  is  generally  sufficient. 


PURPURA. 

Purpura  is  the  name  applied  to  spontaneous  subcutaneous  hemor- 
rhages. These  may  be  either  small,  about  the  size  of  a  pinhead 
(petechiiv),  or  they  may  be  larger  and  resemble  a  bruise  (ecchymoses). 
When  limited  to  the  skin  the  condition  is  spoken  of  as  purpura  simplex. 
In  severe  cases,  however,  there  are  hemorrhages  under  the  mucous 
membranes  and  into  the  internal  organs  and  sometimes  actual  bleeding. 
These  are  called  purpura  hemorrhagica.  These  are  only  degrees  of 
the  same  condition  and  the  classification  is  unsatisfactory.  Other  ways 
of  separating  the  purpuras  are  nearly  as  bad  as  the  causes  underlying 
the  condition  are  but  little  understood. 

Etiology. — Purpura  may  be  regarded  as  a  symptom  sometimes 
secondary  to  a  known  condition,  but  at  other  times  apparently  the 
chief  symptom  of  some  primary  disease. 

Symptomatic  purpura  occurs  in  the  course  of  a  large  number  of 
diseases  and  conditions  the  most  important  of  which  are  as  follows: 

Injections. — It  occurs  in  the  course  of  many  of  the  ordinary  infectious 
diseases  and  infections;  in  smallpox,  scarlet  fever,  measles,  cerebrospinal 
fever,  diphtheria;  in  hereditar\^  syphilis,  the  sey)tic  infections,  septicemia, 
pyemia,  and  nuxlignant  endocarditis.  When  it  occurs  in  the  infectious 
diseases  the  name  "black"  is  prefixed  by  the  laity  as  "black  measles." 
The  prognosis  in  these  cases  is  very  bad  and  the  patients  usually  die.  In 
making  the  prognosis  it  should  be  remembered  that  a  cachectic  purpura 
may  appear  late  in  the  course  of  any  of  the  above,  especially  measles, 
and  that  while  this  is  apt  to  be  in  the  severe  and  unfavorable  cases 
it  is  by  no  means  always  so. 

Cachectic. — In  this  form  the  skin  only  is  involved,  as  a  rule.  This 
is  very  common  in  infancy,  particularly  in  institutions.    When  it  occurs 

1  New  York  Medical  Journal,  November  11,  1905. 


DISEASES  OF  THE  BLOOD  829 

it  has  nearly  always  a  very  grave  import.  The  commonest  form  is  that 
which  is  seen  in  marantic  infants  over  the  abdomen,  but  sometimes 
on  other  parts  of  the  body  as  welh  It  is  also  seen  in  bronchopneumonia, 
in  empyema,  ileocolitis,  in  tuberculosis,  in  nephritis,  in  Hodgkin's 
disease,  when  there  are  malignant  growths,  in  the  course  of  diseases  of 
the  blood,  especially  pernicious  anemia  and  leukemia.  Scurvy  might 
be  added  to  the  Hst. 

Toxic. — This  is  the  form  resulting  from  the  administration  of  drugs, 
ptomaine  poisoning,  and  in  the  course  of  jaundiced  conditions.  Among 
the  drugs  which  may  at  times  cause  purpura  are  quinine,  copaiba, 
mercury,  belladonna,  ergot,  the  iodides,  potassium  chlorate,  antipyrin, 
arsenic,  salicylic  acid,  and  chloral. 

Mechanical. — This  is  seen  in  epilepsy,  whooping-cough,  and  very 
commonly  after  the  removal  of  splints. 

Hemorrhage  into  the  Adrenal. — As  Dudgeon  has  pointed  out,  pur- 
pura is  a  symptom  of  this  lesion.  (See  Hemorrhage  into  the  Adrenal, 
p.  849.) 

Neurotic. — Tliis  is  rare  in  young  cliildren;  it  may,  however,  be  seen 
about  puberty. 

Primary  Purpura. — This  comes  on  without  any  apparent  cause. 
The  classification  of  cases  is  varied  according  to  the  author.  Clinically 
the  following  forms  may  be  considered:  Purpura  simplex,  purpura 
hemorrhagica,  purpura  fulminans,  Henoch's  purpura,  purpura  rheu- 
matica,  and  giant  purpura  without  symptoms. 

The  condition  needs  further  study  on  all  points,  as  there  are  many 
discrepancies  in  the  statements  of  observers.  Some  state  that  it  is 
most  frequent  from  two  to  ten  vears  of  age;  others  that  it  is  more  fre- 
quently seen  from  nine  to  fifteen  years.  In  some  collections  of  cases 
the  sexes  are  given  as  about  equal;  in  others  boys  preponderate. 

Pathology. — This  is  obscure.  The  lesion  consists  in  the  hemorrhagic 
exudate  in  the  skin,  mucous  membranes,  and  internal  organs.  The 
spleen  may  or  may  not  be  enlarged.  Ulcers  have  occasionally  been 
found  in  the  stomach.  The  adrenals  are  generally  the  seat  of  enormous 
hemorrhages.  There  are  no  characteristic  changes  in  the  blood.  There 
is  usually  an  anemia  of  a  secondary  type,  "^dth  or  without  leukocytosis. 

Gangrene  has  occasionally  been  noted. 

Various  theories  have  been  advanced  to  explain  the  condition.  The 
principal  ones  are  (a)  that  it  is  an  infection,  {h)  that  it  is  due  to  vaso- 
motor changes,  and  (c)  that  it  is  due  to  endarteritis. 

Symptomatology.  Purpura  Simplex. — In  this  form  the  hemorrhage 
is  limited  to  the  skin.  The  child  may  go  to  bed  well  and  in  the  morning 
the  petechia?  be  noticed.  More  frequently  there  are  prodromes  consist- 
ing of  general  indisposition.  After  two  or  three  days  or  even  longer  the 
purpura  appears.  At  the  same  time  there  are  liable  to  be  disturbances 
of  digestion,  nausea,  vomiting,  and  in  some  diarrhea.  There  is  usually 
some  fever,  the  temperature  ranging  from  100°  to  103°  F.  The  purpura 
consists  of  fine  petechiae  and  small  ecchymoses.  These  generally 
appear  first  on  the  legs  and  then  on  the  remainder  of  the  body.    At  first 


830      DISKASKS  OF  BLOOD,  LYMPHATIC  SYSTEM  A\D  GLAXDS 

tlu'y  arc  of  a  l)rip;ht  red  or  purplisli  color,  l)ut  soon  turn  darker  and 
become  bluish  blaek.  They  do  not  disappear  on  pressure.  There  may 
or  may  not  be  joint  pains.  The  disease  lasts  from  one  to  four  weeks. 
Ilela})ses  are  common.  The  outlook  is  good,  nearly  all  the  cases  recover- 
ing. The  prognosis  should  always  be  carefully  given,  as  sometimes  a 
mild  case  terminates  rather  suddenly  in  death. 

PURPUKA  Hemokhiiacjica. — The  name  morbus  maculosus  Werlhofi,so 
often  applied  to  this,  really  l)elongs  to  the  disea.se  which  Werlhof  described 
as  f/{a)it  purpura  icUhout  symptoms  (p.  832). 

Purpura  lu'inorrhagica  is  a  severe  disease.  It  may  bear  some  resemblance 
totyplioid  in  its  fever,  course,  prostration,  and  duration.  The  temperature 
ranges  from  101°  to  103°  F.  or  more.  The  j)rostration  is  usually  extreme. 
There  are  nausea,  vomiting,  and  generally  diarrhea.  There  may  or  may 
not  be  albuminuria.  The  hemorrhages  are  the  striking  feature  of  the 
disease.  These  may  come  on  at  the  same  time  a,s  the  purpura  or  even 
precede  it.  The  skin  is  mottled  with  petechije  and  ecchymoses.  They 
vary  from  the  size  of  a  pinhead  to  half  an  inch  in  diameter.  Their  color 
varies  from  a  red-wine  color  to  a  blackish  red.  They  do  not  disaj)pear 
on  pressure.  At  times  they  may  be  painful  or  may  itch.  The  purpura 
may  be  present  on  the  mucous  membranes.  Slight  external  wounds 
cause  a  profuse  hemorrhage  like  that  described  in  hemophilia.  Bleeding 
may  take  place  spontaneously  from  any  mucous  membrane.  Bleeding 
from  the  nose  is  the  most  common.  It  was  present  in  77  out  of  100 
cases  (Barthez  and  Sannee).  Bleeding  from  the  mouth  is  common, 
especially  from  the  gums.  The  hemorrhage  may  come  from  the  tonsils 
or  pharynx.  In  these  cases  the  breath  is  very  fetid.  Hemorrhage 
directly  from  the  stomach  is  more  rare.  Blood  may  be  swallowed  from 
bleeding  in  the  mouth  or  nose  and  then  vomited.  Intestinal  hemor- 
rhages may  also  take  place.  Black  stools  result,  but  these  may  come 
from  swallowed  blood.  If  the  blood  passed  from  the  l)owel  is  bright 
red  it  is  certainly  from  the  lower  part  of  the  intestines.  Hematuria 
may  be  present,  but  is  not  of  very  frequent  occurrence.  Hemoptysis  is 
extremely  rare  in  purpura.  Bleeding  may  take  place  from  the  female 
genitalia.  There  may  be  retinal  or  choroidal  hemorrhages.  Intra- 
cranial hemorrhages  are  rarely  seen.  Edema  may  be  present.  Its 
location  and  extent  vary.  Pains  may  be  complained  of  in  almost  any 
part  of  the  body.  Headache,  backache,  and  pains  in  the  abdomen  are 
the  most  frecjuent.  The  anemia  from  the  rc^peated  hemorrhages  may 
be  extreme. 

There  may  be  marked  nervous  symptoms  in  some  cases.  These  may 
be  merely  general  nervousness  and  anxiety  or  in  other  cases  there  may 
be  delirium,  stupor,  or  even  coma. 

The  course  of  the  disease  is  variable.  It  lasts  from  one  to  six  weeks. 
In  some  the  patients  after  a  few  days  pass  into  a  typhoid  state.  This 
should  not  be  confused  with  typhoid  fever  with  a  purpuric  eruption. 
These  cases  are  generally  fatal.  Purpura  hemorrhagica  is  always  a 
serious  disease,  but  especially  so  in  the  weak,  the  very  young,  and  where 
there  are  symptoms  suggestive  of  septic  infection. 


DISEASES  OF  THE  BLOOD  831 

Diagnosis. — The  diagnosis  is  easy.  Typhoid  may,  of  course,  be 
distinguished  by  means  of  the  Widal  reaction. 

Purpura  Fulmixaxs. — This  is  a  very  acute  fatal  form  of  purpura 
rarely  seen.  It  occurs  most  frequently  under  five  years  of  age;  older 
individuals  may  be  affected.  INIany  cases  of  "black  measles,"  "black 
scarlet  fever,"  and  "black  smallpox"  dxing  rather  suddenly  without 
other  eruption  than  the  purpura  seem  to  belong  to  this  class.  Its  occur- 
rence in  unvaccinated  infants  suggested  that  it  might  be  smallpox  in 
some  instances,  but  other  cases  of  smallpox  have  not  been  noted  after 
the  purpural  eruption. 

Large  hemorrhages  have  been  noted  in  the  adrenals  in  some  of  these 
cases.  The  cases  are  usually  sporadic,  but  a  small  epidemic  has  been 
reported.  The  child  is  taken  suddenly  ill  with  a  chill  or  convulsion, 
vomiting,  high  temperature,  and  marked  constitutional  disturbance. 
The  purpura  comes  on  with  extreme  rapidity,  covering  the  body  in  a 
few  hours  or  a  day.  There  may  be  vesicles  filled  with  blood.  The 
purpuric  eruption  may  affect  the  mucous  membranes,  but  actual 
hemorrhages  are  not  common.  There  is  delirium  or  stupor  and  coma. 
Albumin  is  found  in  the  urine.  The  spleen  is  usually  enlarged.  Death 
may  take  place  in  ten  or  twelve  hours,  or  the  child  may  live  two  or  three 
days.    The  patients  do  not  live  over  five  days. 

Hexoch's  Purpura. — This  remarkable  symptom-complex  was  first 
described  l)y  Henoch,  and  recently  Osier  has  called  attention  to  it  and 
similar  conditions  in  his  articles  on  the  ^^sce^al  manifestations  of  the 
erythema  group.^  The  condition  is  most  frequently  seen  in  childhood, 
has  a  tendency  to  recur  at  varying  intervals,  and  may  be  seen  in  adult 
life.  The  symptoms  may  be  grouped  under  three  heads — skin,  visceral, 
and  arthritic.  The  most  frequent  skin  lesion  is  a  purpura,  but  there  may 
be  urticaria,  circumscribed  edema,  or  erythema  exudativum.  Any  or  all 
of  these  may  be  present  or  only  one.  They  are  liable  to  be  most 
pronounced  at  the  period  when  the  visceral  and  joint  lesions  are  most 
marked,  but  not  necessarily  so. 

The  visceral  symptoms  are  numerous.  INIost  important  of  these  are 
gastroenteric  crises  consisting  of  colic.  These  attacks  of  pain  may  or  may 
not  be  accompanied  by  vomiting,  diarrhea,  or  the  vomiting  of  blood; 
any  one  or  all  three  may  be  present.  These  attacks  last  from  a  few 
hours  to  days. 

Occasionally  there  may  be  cerebral  symptoms.  The  patient  may  be 
slightly  or  markedly  delirious.  Hematuria  and  nephritis  may  occur, 
but  are  rare.  They  may  apparently  be  causes  of  death.  Hemorrhage 
from  the  mucous  membranes  occurs  in  some  cases.  Pulmonary  symp- 
toms, cough,  bronchitis,  and  emphysema  are  occasionally  present. 

The  joint  lesions  consist  of  swelling  of  the  joint,  of  the  synovial  sheaths, 
or  of  the  periarticular  tissues.  One  or  more  joints  may  become  affected. 
Sometimes  there  may  be  a  severe  polyarthritis  like  an  acute  rheumatism. 

The  attacks  recur  at  intervals  of  weeks,  months,  or  even  years.    The 

1  American  Journal  of  the  Medical  Sciences,  January,  1904, 


832       DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AM)  GLANDS 

colic  and  joint  pain  arc  usually  present  in  most  of  the  attaeks.  The 
most  interestini;  point  is  that  the  skin  manifestations  vary;  in  one 
attaek  they  may  be  purpura  in  a  seeond  urtiearia  and  so  forth.  The 
prognosis  is  none  too  good.    Over  25  per  cent,  of  Osier's  cases  died. 

PiHi'iiKA  RiiKiiMATiCA  (Sckonlciii's  Discihsc). — This  is  not  as  com- 
mon in  children  as  in  young  adults,  Init  it  docs  occur,  rarely  under  five 
years,  howevtM*.  'I'hese  ca^es  have  been  regarded  by  some  as  rlu>umatism 
phis  purpura,  by  others  as  a  separate  disease.  The  clinical  picture  is  so 
distinct  as  to  be  easily  recognized.  It  is  characterized  by  a  multiple 
arthritis  resembling  rheumatism  or  })y  actual  rheumatism,  and  in  addition 
there  is  ])urpurie  eruption  consisting  of  j)ctechia'  and  small  ecchymoses; 
there  are  urticaria  and  skin  lesions  which  might  be  put  down  as  erythema 
exudativum  or  erythema  multiforme.  In  some  cases  there  may  be 
edema  and  this  may  at  times  be  very  marked.  The  location  and  amount 
of  edema  are  variable.  There  is  frequently  fever.  This  is  not  very  high, 
but  generally  ranges  from  101°  to  10.3°  F.  The  disease  frequently  begins 
with  a  sore  throat.  There  may  be  albumin  in  tlie  urine.  The  disease 
busts  about  three  weeks  and  the  tendency  is  nearly  always  to  recovery. 
Relapses  are  common. 

The  diac/nosis  is  easy.  The  joint  symptoms,  the  urticaria,  the  ery- 
thema with  the  purpura  form  a  clear  picture. 

Giant  Purpura  without  Symptoms. — This  rare  form  of  purpura 
was  described  by  Werlhof  in  1735  under  the  name  of  Morbus  Maculosus 
Hemorrhagicus.  By  singular  misfortune  the  name  morbus  maculosus 
Werlhofi  is  usvially  applied  to  the  ordinary  severe  form  of  purpura 
hemorrhagica.  There  is  unfortunately  a  great  difference  of  opinion  in 
regard  to  all  forms  of  purpura  and  there  are  wide  variations  in  the 
application  of  terms.  The  disease  in  question  is  most  frequently  seen 
between  the  ages  of  five  and  fifteen,  although  it  may  be  seen  either 
earlier  or  later.  Its  distinguishing  characteristics  are  that  its  onset  is 
sudden  with  a  purpuric  rash  and  sometimes  with  hemorrhages  from  the 
mucous  membranes  of  the  nose,  stomach,  etc.  There  is  neither  fever 
nor  joint  trouble,  and  no  symptom  but  the  bleeding.  The  purpura 
consists  of  petechia',  and,  what  is  most  important,  of  very  large  ecchy- 
moses; these  may  be  several  inches  in  diameter.  They  last  from  one 
to  two  weeks  and  disappear.  Occasionally  they  may  last  longer.  The 
purpura  may  recur.  Practically  the  outlook  is  always  good.  Hemor- 
rhage occurring  in  an  internal  organ,  however,  may  cause  death. 

The  diagnosis  is  easy;  the  size  of  the  spots  and  absence  of  fever  and 
symptoms  are  the  princiyjal  points  to  be  considered.  From  trauma  it 
is  at  times  difficult  and  may  depend  upon  the  history,  which  may  be 
important  from  a  medico-legal  standpoint.  The  finding  of  hemorrhagic 
spots  on  the  mucous  membrane  will  hely)  as  showing  the  disease.  Such 
ca,ses  have  been  regarded  as  mild  atypical  scurvy,  but  they  occur  at  an 
age  when  scurvy  is  rare  and  there  are  none  of  the  other  symptoms. 

Treatment. — The  treatment  of  secondary  purpura  consists  in  the 
management  of  the  original  disease  and,  if  practicable,  the  suggestions 
made  for  primary  purpura  may  be  added. 


DISEASES  OF  THE  BLOOD  333 

In  'primary  purpura,  especially  in  the  severer  forms,  the  child  should 
be  kept  quiet  in  bed  and  guarded  from  all  injuries  and  bruising.  The 
diet  is  perhaps  the  most  important  thing.  This  should  be  on  the  same 
lines  as  that  recommended  in  scur\7.  Fresh  fruit  juices,  fresh  vegetables, 
fresh  milk  and  meats  may  be  used  as  freely  as  possible.  In  the  severer 
cases  orange-juice  may  be  added  to  the  milk  or  other  hght  diet  that  is 
being  used.  The  diet  should  be  kept  up  during  convalescence.  Some 
cases  seem  to  be  greatly  benefited  by  it,  vihile  others  are  but  httle  affected. 
A  great  many  drugs  have  been  tried.  AdrenaHn  may  be  given  in  doses 
of  0.06  c.c.  (1  drop)  or  more  of  the  1 :  1000  solution  several  times  a  day. 
The  mineral  and  vegetable  acids  and  the  astringent  drugs,  such  as  gallic 
acid  and  hamamelis,  are  recommended.  The  very  severe  forms  should 
be  treated  symptomatically.  During  convalescence  careful  feeding  and 
tonics  should  be  used.  Iron,  if  the  child  is  anemic,  is  one  of  the  most 
important. 

HEMOPHILIA. 

Hemophilia  is  a  curious,  rare  disease  of  a  family  and  hereditarv 
nature,  characterized  by  a  tendency  to  grave  hemorrhage  from  verv 
slight  causes.     Popularly  these  patients  are  called  "  bleeders." 

Etiology. — The  disease  runs  in  certain  families  and  has  been  known 
to  persist  through  seven  generations,  covering  a  period  of  two  hundred 
years.  Isolated  cases  have  been  reported,  however,  where  there  was 
apparently  no  family  taint.  It  has  been  looked  upon  as  a  stigma  of 
degeneration.  It  occurs  more  frecjuently  in  boys  than  in  girls.  Dunn^ 
has  collected  7S0  cases,  717  being  in  males  and  63  in  females.  "The 
female  members  of  bleeder  families  are  par  excellence  conductors  of 
the  dLsposition.  The  daughters  in  bleeder  families  are  comparativelv 
exempt  from  the  tendency,  while  the  sons  are  liable  to  it.  Thev  may 
themselves  be  healthy  and  marry  healthy  husbands,  yet  the  bleeder 
habit  is  likely  to  be  conducted  to  their  sons.  The  daughter  of  a  bleeder 
family,  herself  a  bleeder,  is  not  more  likely  to  transmit  the  tendency  than 
her  non-bleeder  sister.  A  son  of  a  bleeder  family,  himself  a  bleeder, 
should  he  live  to  beget  children,  does  not  often  conduct  the  disease  to 
his  children,  but  to  his  grandsons  through  his  daughters.  Again,  should 
he  have  non-bleeder  brothers,  their  grandsons  seldom  bleed."  (Dunn.) 
The  families  are  exceedingly  prolific  and  a  little  over  half  of  the  children 
have  the  disease.  It  is  more  common  in  cold  climates  than  in  warm 
and  seems  to  be  unknown  in  the  tropics.  It  is  found  in  certain  com- 
munities with  great  frecjuency,  supposedly  from  intermarriage  of 
members  of  hemophilic  families.  It  is  said  to  be  most  frecjuent  in 
Germans  and  Hebrews.  It  usuallv  begins  in  the  first  two  years  of  life, 
and  is  rarely  seen  to  begin  after  ten  years  of  age  and  practically  never 
after  twentv.  Grandidier  crives  65  cases  in  bovs.  Of  these  62  began 
before  the  tenth  year  and  40  in  the  first  year.     Joint  affections  and 

1  American  Journal  of  the  Medical  Sciences,  1883,  vol.  Ixxxv. 
53 


834    disi:asi:s  of  blood,  lymphatic  system  axd  glands 

asthma  may  he  met  witli  in  tlicso  families.  Similar  transmission  of 
(lisoasc  throuiih  the  (laughttM's  has  sometimes  been  seen  in  cases  of 
diabetes  insipidus,  Duehenne's  paralysis,  color  blindness,  <rreat  thirst,  etc. 

Pathology. — This  is  unknown.  It  has  been  supposed  that  there  is 
thinness  of  the  coats  of  the  arteries  and  degenerations  of  the  walls. 
This,  however,  does  not  stand  on  a  very  firm  ba,sis.  There  is  no 
chan(;(>  in  the  blood  except  that  the  coagulability  is  delayed.  After 
the  hemorrhages  there  may  be  a  temporary  secondary  anemia. 

Symptomatology. — The  symptoms  are  very  simj)le.  Following  slight 
injuries,  as  abrasions,  scratches,  erosions,  superlicial  cuts,  and  the  like, 
there  is  severe  and  sometimes  uncontrollable  hemorrhage.  The  bleeding 
is  more  of  an  oozing  than  of  violent  hemorrhage,  but  the  (juantity  of 
blood  lost  in  a  short  time  may  be  enormous.  Cases  have  been  reported 
where  the  amount  was  a  pint  or  even  a  quart  in  a  few  hours.  The 
bleeding  may  last  a  week,  with  remissions  and  intermissions.  There  is 
a  tendency  to  bleed  from  mucous  membranes.  Hemorrhage  from  the 
nose  or  from  the  l)owel  may  take  place.  There  are  apt  to  be  petechite, 
ecchymoses,  and  hematoma-s.  They  may  result  from  trifling  bruises. 
When  the  hemorrhage  is  not  traumatic  prodromes  are  sometimes 
observed.  There  is  a  rush  of  blood  to  the  head,  acuteness  of  hearing 
or  of  sight,  buzzing  in  the  ears,  deafness,  disturbances  of  vision,  epile])ti- 
form  convulsions,  or  attacks  of  laughing  or  excitement.  These  pass  off 
when  the  hemorrhage  begins.  It  is  interesting  to  note  there  are,  as  a 
rule,  no  disturbances  of  menstruation  beyond  a  tendency  to  early  and 
rather  profuse  flow,  nor  is  there  any  unusual  bleeding  at  childbirth. 

There  may  be  effusions  of  blood  into  the  joints,  the  order  of  fre- 
quency being  the  knee,  foot,  hip,  shoulder,  and  elbow.  The  affections 
of  the  joint  include  acute  effusions  with  or  without  fever,  arthropathies 
with  swelling  and  deformity  which  may  be  mistaken  for  other  joint 
troubles,  and  extensive  joint  changes,  often  with  ankylosis,  which  resem- 
ble a  form  of  arthritis  deformans. 

The  sym])toms  following  the  bleeding  are  those  of  any  severe  hemor- 
rhage. Death  may  take  place  with  convulsions.  In  favorable  cases 
the  patient  is  liable  to  fall  into  a  deep,  prolonged  sleep  from  exhaustion. 

Three  forms  of  the  disease  have  been  described :  L  The  severe  form, 
in  which  there  is  a  tendency  to  severe,  spontanetnis  or  traumatic  hemor- 
rhages, associated  with  swelling  of  the  joints.  This  is  seldom  seen  in 
females,  generally  lasts  through  life,  and  usually  is  the  cause  of  death. 
2.  The  intermediate,  in  which  there  is  no  tendency  to  joint  affection 
or  traumatic  hemorrhages,  but  frecjuent  spontaneous  ones  from  mucous 
surfaces  and  subcutaneous  ecchymoses.  This  form  frecjuently  appears 
at  pul)erty.  'A.  A  mild  form  seen  only  in  females;  there  are  ecchymoses 
and  early  and  prolonged  menstruation. 

Diagnosis. — This  is  made  from  the  bleeding,  which  is  spontaneous  or 
follows  slight  caus(>s,  the  difficulty  of  stopping  such  hemorrhages,  and 
the  history  of  the  disease  in  the  family  and  of  j)revious  attacks.  The 
history  of  the  presence  of  the  joint  troubles  may  be  of  some  value. 
Care  should  be  taken  to  exclude  the  hemorrhagic  diseases  of  the  new- 


DISEASES  OF  THE  BLOOD  835 

born,  which  are  of  a  different  nature.  Bleeding  from  the  umbilicus  is 
rarely  hemophilia.  Scurvy  may  be  mistaken  for  hemophilia.  The 
treatment  by  dietetic  means  soon  clears  up  the  doubt.  Leukemia  or 
severe  anemias  can  be  excluded  by  a  blood  examination.  Purpuric 
conditions  are  acute,  and  if  the  child  lives  there  is  no  tendency  to 
hemorrhage  left  behind. 

Prognosis. — Prognosis  is  worse  in  boys  than  in  girls.  The  longer  a 
bleeder  lives  the  less  liable  is  he  to  die  of  his  peculiar  disease. 

Grandidier  gives  the  following  interesting  table  of  212  fatal  cases 
— 197  males,  15  females: 

Males.    Females.     Total. 

Within  the  first  year 22  7  29 

From  one  to  seven  years 89  3  92 

"     eight  to  fourteen  years -  39  1  •         40 

"     fifteen  to  twenty-one  years 24  3  27 

"     twenty-two  to  twenty-eight  years  ......  8  ..  8 

"     twenty-nine  to  thirty-five  years 6  1  7 

"     thirty-five  to  forty-five  years 3  ..  3 

Over  fifty  years 6  ..  6 

Almost  all  of  the  cases  observed  die  before  they  are  ten  years  of  age, 
nearly  all  the  remainder  before  they  are  twenty,  while  if  they  go  past 
that  age  they  are  apt  to  die  of  some  other  affection. 

Treatment. — Prophylaxis  consists  in  preventing  the  marriage  of 
bleeders  where  possible,  especially  of  the  daughters.  After  the  child  is 
born  it  should  be  guarded  from  injuries  of  all  kinds.  As  the  disease 
is  not  seen  in  hot  climates  the  removal  to  some  tropical  place  has  been 
advised  and  has  been  successful  in  a  few  cases. 

When  hemorrhage  occurs  the  child  should  be  kept  at  absolute  rest. 
If  the  part  is  accessible  pressure  should  be  applied.  All  sorts  of  styptics 
have  been  advised  and  may  do  good.  Tannic  acid  and  perchloride  of 
iron  have  perhaps  given  the  best  results.  Of  course,  operative  measures 
are  to  be  advised  against. 

Adrenalin  1 :  1000  may  be  applied  directly  to  the  spot  or  given  inter- 
nally in  hemorrhage  from  the  stomach.  Cocaine  solutions  may  also  be 
used  in  place  of  this.  Ergot  has  been  used  with  success  in  some  cases. 
Sulphate  of  soda  in  small  doses,  0.13  gm.  (2  gr.),  repeated  every  two 
hours  has  been  recommended.  The  liquor  of  perchloride  of  iron  in 
2  c.c.  (half-drachm)  doses  has  been  used  by  Legg.  Gelatin  in  5  per 
cent,  solutions  injected  subcutaneously  has  been  recommended.  Care 
should  be  taken  to  have  it  sterile.  Gelatin  solutions  by  mouth  may  be 
tried.  A  salt  solution  may  be  tried  by  enema,  but  seems  to  be  of  little 
or  no  definite  value. 


CHAPTER  XXXIII. 

THE  THYMUS— STATUS  LYMPHATICUS— ADENITIS— HODGKIN'S 
DISEASE— THE  SPLEEN. 

THE   THYMUS  GLAND. 

The  gland  extends  from  the  notch  of  the  sternum  or  somewhat  above 
it  as  far  down  as  the  second,  third,  or  fourth  costal  cartilatje.  Its  width 
varies  from  1  to  2.5  cm.  (half  an  inch  to  about  an  inch).  It  varies 
considerably  in  size  in  different  individuals,  according  to  their  age, 
size,  and  state  of  nutrition.  It  increases  from  birth  to  about  two  years 
rather  rapidly,  slowly  from  that  time  until  ])uberty,  when  it  remains 
stationary  until  twenty-five  or  thirtv  is  reached,  then  it  atrophies  and 
is  replaced  by  fat  and  connective  tissue.  It  weighs  about  3  gni.  at  birth, 
about  5  gm.  at  the  second  year,  and  from  7  to  12  gm.  later  on,  according 
to  some  authorities,  while  others  give  14  gm.  at  birth,  20  gm.  at  the 
ninth  month,  and  25  to  30  gm.  at  the  se^cond  year.  The  latter  figures  are 
])erhaps  the  more  reliable. 

The  function  of  the  thymus  is  not  definitely  known.  Briefly  stated 
the  chief  theories  are  as  follows:  Kolliker  and  Beard  think  that  it  is 
the  parent  source  of  the  leukocytes;  Chiari  and  Ziegler  that  it  acts  in 
place  of  the  Ivmphatic  system  in  intrauterine  life  until  it  is  replaced 
by  other  lymph-forming  organs  (pharyngeal  and  faucial  tonsils)  taking 
up  its  function.  It  is  intimately  connected  with  the  Ivmphatic  system, 
as  it  is  enlarged  in  general  lymphatic  enlargement.  It  atrophies  in  the 
atrophy  of  the  lymphatics  such  as  that  following  thyroidectomy.  It 
has  some  relation  with  the  spleen.  Fricdlcben  found  that  as  the  spleen 
got  larger  the  thymus  grew  smaller.  When  there  are  numerous  nucleated 
red  blood  cells  in  the  spleen  there  are  few  in  the  thymus  and  vice  versa. 

It  seems  to  bear  a  close  relation  to  the  state  of  nutrition,  the  develop- 
ment and  growth  of  the  individual.  Both  macroscopically  and  micro- 
scopically it  is  a  good  index  to  the  state  of  nutrition  of  infants.  In  well- 
nourished  infants  the  thymus  is  well  developed,  in  moderate  atrophy 
it  is  small.  The  most  marked  pathological  change  in  it  is  found  in  the 
extreme  atrophies  of  infancy,  both  primarv  (marasmus)  and  that 
secondary  to  wasting  diseases.  In  these  cases  it  is  atrophied  and  much 
of  the  gland  replaced  by  fibrous  tissue.^ 

The  thymus  may  be  altered  by  changes  in  general  diseases,  such  as 
syphilis  and  tuberculosis,  and  may  be  the  seat  of  tumors  of  various 
kmds  and  of  abscesses.  Hemorrhages  are  of  frequent  occurrence, 
especially  in  infants  who  have  been  asphyxiated.     It  has  been  found  to 

1  stokes,  Ruhriih,  and  Rohrer,  American  Journal  of  the  Medical  Sciences,  November,  1902, 
(836) 


STATUS  LYMPH ATICUS  837 

be  hypertrophied  in  some,  but  not  all,  cases  of  acromegaly  (43  per  cent.), 
gigantism,  Graves'  disease,  chlorosis,  leukemia,  Hodgkin's  disease, 
epilepsy,  and  somewhat  in  infections,  although  authors  differ  on  this 
point.  It  is  also  hypertrophied  in  thymic  asthma  and  in  Paltauf's  status 
thymicus  (status  lymphaticus). 

It  is  atrophied  in  atrophic  conditions  of  the  body  and  in  rickets.  In 
idiots.  Bourne ville  found  it  was  present  in  only  27  per  cent.  Katz 
found  it  present  in  every  case  in  sixty-one  autopsies  on  mentally  sound 
children. 

Hypertrophy  of  the  Thymus.  Sudden  Death. — The  thymus  may  be 
enlarged  in  the  course  of  various  diseases  as  mentioned  above,  or  it  mav 
become  enlarged  alone.  When  this  happens  and  the  gland  reaches  a 
sufficient  size  it  causes  symptoms  and  may  be  a  cause  of  sudden  death 
in  young  children  and  infants,  or  in  older  individuals  with  Pidtauf's 
status  thymicus.  The  history  of  these  cases  is  usually  that  the  infant 
has  been  put  to  bed  perfectly  well  or  sometimes  with  a  slight  cyanosis. 
WTien  next  seen  it  is  dead  with  marked  lividity  of  the  body.  Autopsy 
reveals  a  large  thymus  weighing  an  ounce  or  an  ounce  and  a  half  (30  to 
45  gm.).  There  are  apt  to  be  hemorrhages  in  the  gland.  It  is  important 
to  bear  this  form  of  sudden  death  in  mind  from  a  medicolegal  point 
of  view. 

Thymic  Asthma. — The  enlargement  may  be  slight  and  may  come  on 
gradually  and  the  condition  may  last  months.  Some  of  the  patients 
with  enlarged  thymus  glands  die  suddenly  after  having  had  symptoms 
for  some  time.  The  symptoms  are  those  of  intrathoracic  pressure. 
There  is  a  pallor  of  the  face  with  usually  a  slight  edema,  especially 
marked  in  the  parotid  region,  under  the  jaw,  and  about  the  eyes.  The 
conjunctivfe  are  suffused  and  may  be  infiltrated  with  blood.  The  lips 
are  cyanosed  to  a  greater  or  less  extent,  as  are  also  the  finger-nails. 
The  respiration  is  labored  and  noisy  with  inspiratory  stridor.  In  some 
this  seems  to  be  the  result  of  direct  pressure  upon  the  trachea  and  in 
others  from  spasm  of  the  larynx. 

There  is  dulness  over  the  upper  part  of  the  sternum  and  the  gland 
may,  in  some  cases,  be  felt  above  it.  The  head  should  be  extended  in 
making  percussion. 

Diagnosis. — ^The  diagnosis  of  the  exact  condition  is  difficult  from 
tumors  or  enlarged  bronchial  lymph  nodes.  This,  however,  is  of  no  great 
practical  importance.  If  the  dulness  is  very  irregular  it  is  usually  due 
to  enlarged  lymph  nodes. 

Treatment. — The  treatment  is  to  remove  the  offending  mass  if  symp- 
toms are  sufficient  to  cause  manifest  trouble.  This  has  been  done 
successfully  a  number  of  times  with  perfect  recovery  and  with  relief 
of  symptoms. 

STATUS  LYMPHATICUS. 

Under  this  name  or  that  of  Status  Th\miicus  a  condition  of  considerable 
interest  has  been  recently  much  discussed.     Paltauf  called  attention  to 


838       DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AXD  GLANDS 

certain  cases  of  young  adults  who  died  rather  suddenly  of  edema  of  the 
brain.  At  autopsy  there  wtis  found  to  be  enlarged  thymus,  general 
hypertrophy  of  the  lymphatic  system,  and  hypoplasia  of  the  vascular 
system,  particularly  of  the  aorta,  and  a  chlorotic  state. 

Other  instances  of  sudden  death  from  trifling  causes  in  infants, 
children,  or  young  adults  have  been  found  to  be  associated  with  a  certain 
phvsical  picture  described  below.  These  deaths  have  been  from  slight 
sunncal  operations;  hypodermic  injections;  falling  into  the  water, 
although  pulled  out  immediately;  shower  baths,  and  the  administration 
of  chloroform. 

Etiology. — This  condition  clinically  may  be  seen  at  any  age,  but 
especially  in  young  children.  At  ])uberty  there  seems  to  be  a  tendency 
for  the  lymphoid  tissues  to  undergo  atrophy  and  in  the  majority  of 
instances  the  individuals  outgrow  hypertrophy  of  lymphatic  structures. 
As  noted  above,  however,  it  may  persist  and  be  followed  by  sutlden 
death. 

In  some  cases  the  condition  seems  to  be  present  at  birth  and  continues 
until  about  puberty  if  the  child  lives.  In  others  it  seems  to  be  accpiired 
later,  enlargement  of  the  lymphatic  structures  apparently  coming  on 
from  slight  causes  and  remaining.  These  acquired  cases  seem  most 
common  in  the  poor  in  institutions  and  tenements,  and  are  often 
associated  with  rickets.  They  should  be  distinguished  from  the  so-called 
scrofulous  or  strumous  children  where  the  lesion  is  tuberculous. 

Pathology. — The  status  lymphaticus  consists  in  enlargement  of  the 
lymph  nodes  and  of  all  the  lymphatic  structures,  of  the  spleen  and 
thymus  gland,  with  also  an  increase  in  the  lymphoid  cells  in  the 
bone-marrow.  These  changes  are  frequently  seen  in  association  with 
rickets.  There  may  also  be  a  hypoplasia  of  the  bloodvessels,  espe- 
cially the  aorta. 

Symptomatology. — The  children  are  usually  pale,  apparently  well 
nourished,  but  often  the  flesh  seems  more  or  le^s  flaV)bv.  The  pharyngeal 
and  faucial  tonsils  are  hypertrophied.  The  ring  of  lymphoid  tissue 
about  the  fauces  is  prominent.  The  lymphoid  follicles  in  th.e  pharynx 
and  about  the  tongue  are  enlarged.  The  circumvallate  papilla*  of  the 
tongue  are  prominent.  The  lymph  nodes  over  the  entire  body  are 
swollen  and  palpable.  The  thymus  is  increased  in  size,  and  dulness 
over  the  upper  part  of  the  sternum  is  easily  made  out.  The  spleen 
is  enlarged  and  easily  palpable.  The  thyroid  is  said  to  be  enlarged  in 
some  cases,  but  this  has  not  been  present  in  the  cases  which  have  come 
under  my  oi)servation.  There  is  a  tendency  to  itching  of  the  skin  and 
to  eczema.  As  noted  above,  rickets  is  frequently,  but  not  always, 
present.  It  is  important  to  recognize  status  lymphaticus,  as  these 
children  have  a  lowered  resistance  and  a  tendency  to  sudden  death. 
Before  administering  chloroform  to  a  child  it  should  be  examined  care- 
fully for  evidences  of  this  condition. 

In  infants  dying  suddenly  there  may  be  status  lymphaticus.  The  history 
is  usually  that  the  child  is  either  found  dead,  or,  if  seen  alive,  there  are 
rolling  of   the  eyes,  a  cry,  and  a   convulsion.     Improper  feeding  may 


SIMPLE  ACUTE  ADENITIS  839 

bring  on  fatal  convulsions,  and  children  who  die  after  slight  indis- 
cretions of  diet  are  of  this  type. 

Treatment. — This  is  not  very  satisfactory,  but,  fortunately,  in  most 
instances  the  status  lymphaticus  is  outgrown.  Good  hygiene  and  good 
food  are  important,  and  plenty  of  fresh  air  and  sunshine  necessary. 
Enlarged  tonsils  and  adenoids  should  l^e  removed.  It  should  always  be 
borne  in  mind  that  these  children  do  not  take  anesthetics  well  and  that 
chloroform  is  especially  dangerous. 

Cod-liver  oil  in  cold  weather  and  the  syrup  of  the  iodide  of  iron  give 
the  best  results  in  the  way  of  drugs.  Iodide  of  potassium  may  be  given 
a  trial. 

SIMPLE  ACUTE  ADENITIS. 

This  is  an  acute  inflammation  of  the  lymph  nodes.  The  lesion  is 
secondary  to  inflammation  or  irritation  elsewhere  in  some  adjacent 
tissue  which  is  drained  by  the  chain  of  lymph  nodes  that  is  affected 
or  is  part  of  some  general  infective  process.  The  external  and  internal 
nodes  are  both  affected.  The  external  suppurate  frequently,  but  the 
internal  apparently  quite  rarely.  The  bronchial  lymph  nodes  are 
affected  in  lesions  of  the  lungs  and  bronchi  (see  p.  351);  the  mesenteric 
in  intestinal  disorders,  etc.;  but  while  these  enlarged  nodes  are  found 
at  autopsy  they  are  not  large  enough,  as  a  rule,  to  be  made  out  during 
life  and  do  not  play  any  very  marked  role  in  ordinary  practice,  except 
as  due  to  tuberculosis,  Hodgkin's  disease,  or  lymphosarcoma,  which  may 
cause  pronounced  symptoms. 

The  external  nodes  are  frequently  enlarged.  Roughly  speaking,  about 
three-fourths  of  the  cases  are  seen  under  two  years  of  age.  Being  near 
the  surface,  they  can  readily  be  palpated.  The  cervical  nodes  are  the  ones 
most  often  affected,  the  axillary  and  the  inguinal  more  rarely. 

In  the  infectious  diseases  the  superficial  nodes  are  quite  regularly 
enlarged,  usually  from  the  result  of  the  local  inflammations.  In  rubella, 
however,  the  posterior  cervical  nodes  are  enormously  enlarged  and  are  of 
some  diagnostic  importance.  The  commonest  causes  of  adenitis  are 
catarrhal  conditions  of  the  nose,  throat,  and  mouth.  The  primary  cause 
may  be  so  slight  as  to  be  easily  overlooked.  Carious  teeth  and  stomatitis, 
especially  ulcerative  stomatitis,  are  frequent  causes  of  the  submaxillary 
nodes  being  inflamed.  Eczema  of  the  scalp  and  the  irritation  due  to 
lice  as  well  as  other  diseases  of  the  scalp  are  frequent  causes  of  the 
posterior  cervical  nodes  being  affected.  Otitis  and  injuries  should  not 
be  forgotten.  The  axillary  lymph  nodes  are  enlarged  from  vaccination 
and  the  inguinal  from  vaginitis. 

Pathology. — The  lesions  consist  in  a  swelling  of  the  node  due  to  acute 
congestion  and  to  a  hyperplasia  of  the  lymphoid  cells.  The  nodes 
feel  hard,  and,  on  section  early  in  the  disease,  are  homogeneous  in 
their  appearance.  The  microscope  shows  a  simple  hyperplasia.  They 
may  remain  hard  and  firm  for  indefinite  periods,  especially  if  there  have 
been  recurrent  attacks  or  continuous  irritation.    If  the  cause  is  quickly 


g40     DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  A\D  GLANDS 

removed  the  nodes  usually  sul)sid(>  after  a  few  weeks  if  they  do  not 
suppurate.  \Vhen  su])puration  occurs  the  nodes  soften,  the  surrounding 
tissue  becomes  infiltrated,  and  a  localized  cellulitis  results.  The  process 
is  usually  unilateral  or,  if  it  involves  both  sides,  one  side  is  almost  always 
much  worse  than  the  other.  If  suj)j)uration  occurs  it  is  liable  to  be  on 
one  side  and  often  only  a  single  node  may  break  down. 

Symptomatology. — The  symptoms  include  the  disease  which  is  the 
cause  of  the  trouble.  Frequently  there  is  diphtheria,  scarlet  fever,  or 
some  other  infection.  There  may  be  a  slight  pharyngitis  which  would 
pass  unnoticed  were  it  not  for  the  extreme  nodular  enlargement  which 
may  follow.  In  these  cases  the  swelling  is  fre(|uently  at  the  angle  of 
the  jaw.  The  lymph  nodes  often  enlarge  very  rapidly,  but  the  swelling 
may  come  on  rather  gradually.  They  are  painful  and  tender  and  there 
may  be  redness  of  the  skin.  Suppuration  when  it  takes  place  usually 
starts  during  the  first  or  second  week,  but  it  may  be  delayed  for  three 
or  even  four  weeks.  After  that  time  suppuration  seldom  occurs.  When 
it  does  occur  there  is  decided  redness  of  the  skin  and  the  swelling  becomes 
more  diffuse.  After  a  few  days  the  little  abscess  which  forms  points 
and  if  not  opened  breaks  through  the  skin.  After  the  pus  is  dischargcxl 
the  healing  is  usually  quite  rapid.  When  suppuration  does  not  occur 
the  nodes  remain  swollen  from  a  week  to  two  months,  gradually  becom- 
ing smaller  and  harder.  They  may  disappear  entirely  or  a  little  hard 
node  may  be  left.  These  nodes  are  liable  to  enlarge  later  on  from 
a  recurrence  of  the  primary  trouble.  When  there  have  been  several 
recurrences,  or  where  the  irritation  is  kept  up  for  a  long  time,  as  that 
from  a  neglected  carious  tooth,  the  no<le  may  remain  hard  throughout 
life  as  an  evidence  of  old  inflammation. 

At  the  height  of  the  disease  there  is  usually  fever. 

Diagnosis. — Diagnosis  is  easy.  The  occurrence  of  enlarged  lymph 
nodes  in  a  child  under  two  years  of  age  or  in  older  children  where  there 
is  a  definite  cause  renders  error  unlikely.  After  two  years  of  age 
tuberculosis  of  the  nodes  is  common.  This  is  a  much  more  chronic 
process.  The  location  of  mumps  in  the  parotid  region  with  the  lobe 
of  the  ear  as  the  centre  of  the  swelling  and  the  history  of  exposure  are 
usually  sufficient  to  differentiate  this  disease.  The  other  node  affections 
are  chronic. 

Treatment. — Where  the  local  cause  is  apparent  it  should  be  treated. 
The  nose,  throat,  or  teeth  should  receive  attention.  Catarrhal  conditions 
of  the  mucous  membranes  should  always  receive  prompt  treatment. 

P'or  the  nodes  themselves  local  applications  of  heat  or  cold  may  be 
applied:  cold,  if  there  is  swelling  and  congestion;  heat,  if  the  process  is 
one  of  pus  formation.  Applications  of  ichthyol,  5  to  10  per  cent.,  either 
as  an  ointment  or  with  glycerin,  may  be  used  and  often  give  consider- 
able comfort.  If  suppuration  takes  place  the  resulting  abscess  should 
be  opened  under  the  usual  aseptic  precautions.  It  is  best  to  wait  until 
the  abscess  "points"  and  then  make  an  incision.  When  suppuration 
does  not  take  place  or  to  hasten  absorption  in  the  remaining  enlarged 
nodes,   iodide   of   potassium  has  been  advised.      It  may  be  given  to 


SIMPLE  CHRONIC  ADENITIS  S41 

infants  in  doses  of  0.06  to  0.19  gm.  (1    to  3  gr.),  diluted  in  water  or 
milk,  four  times  a  day. 

The  usual  painting  with  tincture  of  iodine  is  valueless. 


SIMPLE  CHRONIC  ADENITIS. 

This  is  not  common  in  severe  forms,  but  mild  grades  of  chronic 
adenitis  are  frequently  seen.  It  results  usually  from  recurring  attacks 
of  acute  adenitis  or  from  chronic  inflammatory  conditions  of  the  mucous 
membranes  with  which  the  nodes  are  connected.  Skin  lesions  or  long- 
standing suppurations  may  also  cause  it.  The  posterior  cervical  nodes 
are  often  found  enlarged  in  poor  children  with  chronic  scalp  disease. 
In  children  with  the  so-called  status  lymphaticus  it  is  one  of  the  features 
of  the  condition  which  has  been  described.  The  tonsils  are  frequently 
enlarged  and  adenoids  may  be  present. 

Symptomatology. — The  manifestations  of  the  disease  are  simply 
slight  swelling  of  the  lymph  nodes,  the  neck  being  the  most  usual 
site.  The  nodes  enlarge  and  remain  so  for  a  few  months  and  then 
generally  subside.  They  may  remain  for  years.  They  are,  as  a  rule, 
not  tender.    They  do  not  tend  to  suppurate. 

Diagnosis. — This  is  chiefly  from  tuberculous  nodes  or  from  Hodg- 
kin's  disease.  The  age  and  the  very  slow  course  are  the  principal 
features.  Most  of  the  cases  where  the  enlargement  is  sufficient  to 
cause  doubt  are  in  infants  under  three.  The  removal  of  a  node  for 
diagnostic  purposes  is  permissible  if  there  is  strong  suspicion  either 
of  tuberculosis  or  of  Hodgkin's  disease. 

Treatment. — Treatment  consists  in  removing  the  cause  where  it  is 
apparent.  Enlarged  tonsils  and  adenoids  if  present  should  be  removed 
and  any  catarrhal  conditions  which  may  exist  should  be  treated.  A 
change  of  climate  may  be  desirable. 

Internally,  cod-liver  oil  may  be  given  in  cold  weather.  Iron  in  the 
form  of  the  syrup  of  the  iodide,  or  iodide  of  potassium,  or  arsenic  in  the 
form  of  Fowler's  solution  may  be  used. 

Tuberculosis  of  the  External  Lymph  Nodes. — This  is  treated  of 
in  detail  under  the  heading  of  Tuberculosis  (p.  351)  and  does  not  need 
further  elaboration  here. 

Syphilitic  Adenitis.— Syphilis,  especially  late  hereditary  syphilis,  may 
occasionally  be  a  cause  of  marked  swelling  of  the  lymph  nodes.  The 
enlargement  is  generally  universal,  but  may  be  localized.  In  some 
instances  it  may  be  associated  with  lesions  in  the  adjacent  tissues. 
The  recognition  that  it  is  syphilitic  rests  on  the  finding  of  other  mani- 
festations of  that  disease  and  on  its  rapid  improvement  on  antisyphilitic 
treatment.  All  these  points  are  discussed  in  full  in  the  chapter  describing 
the  disease  and  its  treatment  (see  p.  563). 


842    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 


HODGKIN'S  DISEASE. 

This  is  known  under  a  great  number  of  names  and  is  confused  with 
other  conditions.  Among  tlie  most  frequent  synonyms  are  Adenie 
(Trousseau);  Anemia  Lymphatica  (Wilks);  Pseudoleukemia  (Cohn- 
heim),  and  (Generalized  liymphadenoma. 

It  is  a  disease  characterized  hy  a  progressive  enlargement  of  the 
lymph  nodes  and  the  spleen  and  the  formation  of  nodules  in  the  inter- 
nal organs  (liver,  spleen,  kidney,  etc.),  and  sooner  or  later  a  secondary 
anemia  and  cachexia. 

It  is  a  disease  of  early  life  and  the  majority  of  the  cases  occur  in  child- 
hood. In  Hodgkin's  origiiuU  report,  in  1S.'32,  some  of  the  cases  noted 
were  in  children.  In  43  cases  collected  by  Clement  Clarke  10  were 
under  ten  years  of  age.    It  is  more  frequent  in  boys  than  in  girls. 

Etiology. — I'hc  exact  cause  is  unknown.  It  has  been  suggested  that 
it  is  the  result  of  an  acute  infection  of  some  unknown  agent,  but  this 
has  not  been  proven.  Some  recent  writers  have  thought  that  it  was 
due  to  the  tubercle  bacillus,  but  while  secondary  infections  with  this 
organism  are  common  the  original  changes  in  the  nodes  can  still  be 
made  out  histologically.  In  some  cases  there  is  no  tu])erculous  com- 
plication. 

Pathology. — The  morbid  anatomy  consists  in  enlargement  of  the 
lymph  nodes,  both  deep  and  superficial,  and  of  the  spleen  as  well  in 
most  cases.  The  nodes  do  not  tend  to  break  down  unless  there  is 
secondary  infection  and  there  is  no  tendency  to  invade  the  surrounding  . 
ti.ssue  as  in  lymphosarcoma.  There  are  lymphomatous  nodules  in  the 
organs  and  there  Ls  involvement  of  the  marrow  of  the  long  bones. 
According  to  the  studies  of  Dorothy  M.  Reed^  the  histological  changes 
are  as  follows:  In  addition  to  the  proliferation  of  the  endothelial  and 
reticular  cells  and  the  formation  of  lymphoid  cells  there  are  seen  char- 
acteristic giant  cells  which  differ  from  the  giant  cells  of  tuberculosis, 
"^riiere  is  proliferation  of  the  connective-tissue  stroma  which  gives  rise 
to  the  hardness  of  the  nodes  noted  as  the  disease  progresses.  There 
are  also  numerous  eosinophiles  found  in  the  nodes.  It  should  not  be 
confused  with  sarcoma  of  the  lymph  nodes  which  has  a  different  his- 
tological structure,  nor  with  tuberculosis  of  the  lymph  nodes  (Fig.  172). 

There  do  not  seem  to  be  any  special  predisposing  diseases.  Tuber- 
culosis Ls  not  found  in  the  family  history  any  more  than  is  usual.  The 
patient  is  usually  in  good  health,  but  there  may  be  chronic  tonsillitis  or 
inflammations  of  the  eye  or  ear  before  the  disease  manifests  itself. 

Symptomatology. — The  disease  starts  almost  always  in  the  neck.  The 
nodes  become  enlarged.  They  are  first  somewhat  soft,  but  later  become 
hard  and  firm.  As  a  rule,  they  are  not  painful.  The  disease  extends  until 
the  other  superficial  and  the  internal  lymph  nodes  have  become  involved. 
The  progress  of  the  disease  is  steady,  but  there  may  be  temporary 
remi.ssions.      The  nodes  do  not  tend  to  break   down  unless  there  is 

'  Johns  Hopkins  Hospital  Reports,  1902,  vol.  x. 


HODGKIX'S  DISEASE 


843 


a  secondary  infection,  and  there  is  no  tendency  to  inyolye  the  skin 
unless  this  happens.  The  disease  may  last  months  with  the  patient's 
general  health  good.  Sooner  or  later,  howeyer,  there  is  a  marked  sec- 
ondary anemia  with  cachexia  and  pronounced  weakness.  This  may 
come    on  in  a    few  months  or  it 

may  be  delayed  for  years.     There  ^i^.  1:2 

is  irregtilar  feyer.  This  may  be 
absent  or  may  be  continuous  or 
may  be  occasionally  of  a  remit- 
tent type.  In  three-fourths  of  the 
cases  the  spleen  is  enlarged. 
Other  s}Tiiptoms  which  may  be 
present  are  pressure  symptom^ 
from  the  masses  pressing  on 
trachea,  bronchi,  neryes,  ureters, 
etc.  There  may  be  bronzing  of 
the  skin. 

Diagnosis. — The  clinical  pic- 
ture is  mtich  the  same  in  lympho- 
sarcoma, but  there  is  a  greater 
tendency  to  inyolyement  of  adja- 
cent tissues,  and  there  is  also  a 
greater  liability  to  pressure  symp- 
toms. The  remoyal  of  a  node 
under  cocaine  anesthesia  for  his- 
tological study  is  the  most  certain 
means  of  diagnosis. 

Tuberculosis. — In  early  cases 
of  tuberculosis  this  may  be  yery 
difhcult.  If  there  is  no  feyer 
tuberculin  may  be  used.  It  is 
certain  and  harmless.  There  is 
usually  ttiberculosis  in  the  lungs 
or  elsewhere  and  there  may  be 
suppuration  of  the  node  or  the 
mattino;  too:ether  of  the  nodes. 
The  remoyal  of  a  node  will  clear  up 
doubtful  cases. 

Leul-emia. — Diagnosis  in  leukemia  is  easy,  as  a  rule,  from  a  blood 
examination,  but  there  are  rare  cases  where  in  a  leukemia  the  leuko- 
c^-tes  haye  fallen  to  normal  or  near  it.  The  structure  of  the  nodes  is 
different. 

Prognosis. — This  is  bad.  Sooner  or  later  the  cases  become  cachectic 
and  die.  The  ayerage  duration  of  hfe  after  the  appearance  of  the 
disease  is  from  one  to  four  years.  Death  is  usually  catised  by  a  sec- 
ondary tuberculosis  or  by  progressiye  weakness  with  general  anasarca. 

Treatment. — Treatment  is  not  yery  satisfactory.  If  the  case  is  diag- 
nosticated early  and  the  enlarged  lymph  nodes  are  only  on  one  side  of 


Hodgkin's  disease.     >Ca,se  of  Drs.  Sherman  and 
Gay  lord,  Archives  of  Pediatrics.) 


844    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

the  neck,  removal  of  the  nodes  is  thouijht  to  have  some  influence  on 
proloncrint;  hfe  and  preventinji',  at  least  for  a  time,  the  prot:;ress  of  the 
tlisea.se.  Osier  thinks  that  the  Roentgen  rays  mav  have  some  influence 
in  selected  cases.  The  patient  should  lead  a  regular  hygienic  life,  with 
plentv  of  fresh  air  and  good  food.  Of  the  drugs  used  arsenic  is  the 
favorite  and  some  results  seem  to  have  been  attained  by  it.  It  may  be 
given  in  fairly  large  doses  over  rather  long  periods  without  causing 
any  trouble.  In  some  cases  it  produces  pigmentation  of  the  skin  and 
in  others  neuritis  may  result.  Fowler's  solution  may  be  given  in  from 
0.13  c.c.  to  0.3  c.c.  (2  to  o^l)  doses  three  or  four  times  a  day.  The 
syrup  of  the  iodide  of  iron  may  i>e  tried  if  the  arsenic  tlisagrees,  or  other 
tonics  may  be  given,  such  as  cod-liver  oil  and  cpiinine.  Phos])horus 
has  been  recommended.  It  is  given  in  doses  from  0.000325  to  0.00005 
gm.  (y^^  to  Yko  g^O-    The  effects  should  be  closely  watched. 


DISEASES  OF  THE  SPLEEN. 

The  spleen  is  of  somewhat  more  value  in  diagnosis  in  infants  and 
children  than  in  adults.  In  the  young  it  is  more  readily  aft'ected  and, 
as  a  general  rule,  more  easy  to  make  out.  The  normal  position  of  the 
spleen  should  be  borne  in  mind.  It  lies  with  the  upper  border  reaching 
about  the  ninth  rib  and  the  lower  border  about  the  eleventh  rib.  Toward 
the  back  it  extends  as  far  as  the  posterior  axillary  line  or  a  little  back  of 
the  end  of  the  eleventh  rib.  In  front  it  extends  to  the  midaxillarv  line 
or  a  little  farther,  but  normally  does  not  pass  a  line  drawn  from  the 
nipple  to  the  end  of  the  eleventh  rib. 

The  splenic  dulness  if  made  out  normally  corresponds  to  the  above. 
In  infants  the  normal  splenic  dulness  Is  so  small  that  it  may  not  be 
possible  to  make  it  out  in  all  eases.  At  best  it  is  uncertain,  as  it  may  be 
obliterated  by  the  abdominal  tympany  or  a  large  spleen  made  to  seem 
smaller,  while  intestinal  contents  may  give  rise  to  dulness  which  may 
be  mistaken  for  the  spleen.  An  exudate  in  Traube's  semilunar  space 
may  cause  a  fusion  of  liver  and  splenic  dulness,  and  this  may  also  occur 
in  great  enlargement  of  either  or  both  organs. 

Palpation  is  much  more  certain  than  percussion.  \Yith  an  infant  it 
is  best  to  have  the  child  lying  on  its  back  on  its  mother's  or  the  nurse's 
lap.  If  the  spleen  cannot  be  felt  in  this  position  the  infant  may  be  turned 
on  the  right  side.  The  hand  should  always  be  warmed  and  then  placed 
gently  on  the  abdomen,  and  as  soon  as  the  muscles  become  accustomed 
to  its  presence  an  effort  may  be  made  to  feel  the  spleen.  The  fingers 
or  one  finger  should  be  approached  to  the  edge  of  the  ribs  between  the 
middle  and  posterior  axillary  lines.  In  young  infants  and  in  those  with 
soft  abdominal  walls  the  spleen  may  often  l)e  felt  just  under  the  edge  of 
the  ribs.  The  finger  should  l)e  held  in  one  place  during  several  inspira- 
tions, when  the  spleen  may  be  felt  touching  the  finger  during  inspiration 
and  disappearing   during  expiration.     Then  moderately  rapid  pawing 


DISEASES  OF  THE  SPLEEN  845 

movements  should  be  gently  made.  If  the  spleen  is  felt  by  this  method 
the  edge  will  be  felt  as  it  slips  past  the  finger.  If  the  spleen  extends 
below  the  margins  of  the  ribs  it  may  be  looked  upon  as  enlarged  unless 
pushed  down  by  a  pleural  effusion.  A  moderately  enlarged  spleen 
extends  2  or  3  cm.  below  the  margin  of  the  ribs,  but  it  may  be  so  large 
as  to  extend  to  the  brim  of  the  pelvis  and  past  the  umbilicus.  All  grades 
may  be  seen.  An  acute  enlargement  rarely  exceeds  2 J  or  5  cm.  (1 
to  2  inches)  below  the  edge  of  the  ribs,  and  if  a  spleen  is  found  larger 
it  is  quite  safe  to  assume  that  it  is  a  chronic  enlargement.  The  inner 
border  is  generally  thin  and  sharp.  About  the  middle  of  it  there  is  a 
notch. 

The  upper  border  of  the  spleen  can  never  be  felt  except  in  the  case 
of  floating  spleen. 

It  should  be  remembered  that  the  spleen,  if  it  moves  during  breathing, 
does  so  not  directly  downward,  but  diagonally  toward  the  right  pelvic 
brim.  The  spleen  enlarges  in  this  direction  as  well.  This  may  be  use- 
ful in  differentiating  tumors  of  other  organs.  Usually  a  tumor  mass  of 
other  organs  moves  directly  downward  during  inspiration.  If  not  too 
large  or  fixed  by  adhesions  the  spleen  may  be  moved  laterally. 

The  liver  is  frequently  enlarged  at  the  same  time  and  the  two  may 
lie  so  close  together  that  it  is  impossible  to  make  out  the  one  from  the 
other.  Sometimes  in  marked  enlargement  of  the  liver  the  fissure  made 
in  the  liver  by  the  round  ligament  may  be  taken  for  the  dividing  line 
between  the  liver  and  spleen.  This  fissure  usually  is  in  line  with  the 
umbilicus. 

The  spleen  may  cften  be  seen  if  enlarged.  In  a  good  light,  with  the 
abdominal  wall  held  on  a  stretch  by  the  hand  of  the  physician,  the  spleen 
may  be  plainly  seen  to  move  with  the  inspirations.  There  may  also  be 
enlarged  superficial  veins  and  a  slight  violet  color  may  sometimes  be 
noted. 

Over  a  very  large  spleen  there  may  be  heard  a  bruit  de  souffle  or  blow- 
ing murmur  similar  to  that  heard  over  a  pregnant  uterus.  This  may 
be  elicited  on  pressure  over  the  larger  vessels.  In  most  conditions  where 
there  is  a  large  spleen  the  child  has  a  peculiar  pallid,  brownish-yellow 
color.     The  skin  has  lost  its  transparency  and  become  "muddy." 

The  position  of  an  older  child  for  examination  should  be  the  same  as 
for  an  adult  where  it  is  possible  to  control  the  child.  The  child  should 
be  flat  on  the  back  with  the  knees  drawn  up  or,  where  possible,  what  is 
much  better,  the  upper  part  of  the  body  should  be  sharply  inclined  against 
the  back  of  the  bed  and  a  pillow.  This  latter  position  allows  the  legs  to  be 
kept  down  and  out  of  the  way,  and  at  the  same  time  permits  of  relaxa- 
tion of  the  abdominal  muscles,  and  has  also  the  advantage  of  allowing 
the  spleen  to  descend  should  it  happen  to  be  movable.  When  the  spleen 
cannot  be  felt  in  this  position,  the  child  should  lie  on  the  right  side  with 
the  legs  flexed  and  the  left  arm  over  the  head.  The  breathing  is  an 
important  part  and  is  best  taught  by  imitation.  The  physician  should 
show  the  child  just  how  to  take  long,  deep  inspirations  followed  by  com- 


S46    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AXD  GLANDS 

plete  expirations.  This  may  l)f  made  into  a  sort  of  play,  and  the 
chihi  may  often  have  his  attention  diverted  from  the  examination 
by  trying  to  keep  time  v^ith  the  physieian's  breathing  and  similar 
tactics. 

Enlargement  of  the  Spleen. — Enhirgement  of  the  spleen  may  be  either 
acute  or  chronic.  As  a  general  rule,  it  may  be  stated  that  all  of  the 
acute  infectious  fevers  are  attended  with  some  enlargement  of  the  spleen. 
This  is  generally  only  a  hyperemia.  In  typhoid  and  malaria  it  is  a 
constant  and  important  diagnostic  feature.  In  cerebrospinal  fever  it 
is  onlv  occasionally  seen,  and  in  mumps  it  is  seldom  enlarged.  The 
spleen  is  enlarged  in  most  of  the  chronic  conditions  met  with  in  early 
life. 

In  rickets  it  is  quite  a  constant  feature  in  the  active  stages  of  the 
disease.  In  diseases  associated  with  l)lood  changes,  as  in  leukemia, 
splenic  anemia,  and  in  the  ])scndolcukemia  of  infants,  the  spleen  is 
very  much  enlarged.  It  is  enlarged  in  Hodgkin's  disease.  In  syphilis, 
in  the  early  and  more  active  stages,  it  is  ciisily  felt  in  the  majority  of 
the  cases.  It  is  also  enlarged  in  some  of  the  later  cases.  There  may 
be  circumscribed  gunnnatous  enlargements,  which  are  seen  late  and 
are  rare;  or  there  may  be  merely  a  diffuse  swelling  of  the  organ,  which 
is  commonly  seen. 

In  acvie  miliary  tuberculosis  the  spleen  is  sooner  or  later  enlarged. 
In  the  other  forms  of  tuberculosis  the  spleen  may  or  may  not  be  affected. 
It  may  often  not  be  enlarged  at  all.  In  other  cases  it  may  be  the  seat 
of  extensive  tuberculous  deposits  and  be  considerably  increased  in 
size. 

The  amyloid  spleen  is  large,  hard,  smooth,  and  thick.  It  is  met  with 
in  cases  where  there  has  been  long-standing  suppuration,  especially 
caries  or  necrosis  of  the  bones.  It  may  also  be  seen  in  chronic  tuber- 
culosis of  the  lungs  and  in  syphilis. 

The  spleen  may  be  the  first  organ  to  show  amyloid  changes.  The 
diagnosis  is  made  from  the  pre-existing  condition  of  the  patient.  There 
is  the  history  of  the  chronic  disease,  general  cachexia,  pallor  of  the  skin, 
emaciation,  and  usually  diarrhea,  albumimiria,  multiple  hemorrhages, 
petechia  and  the  like.  In  the  early  stage  the  spleen  alone  may  be 
enlarged.  If  the  condition  has  been  existing  sometime  the  liver  is  also 
enlarged.    This  is  the  condition  called  "sago  spleen"  by  the  old  writers. 


CHRONIC  PASSIVE  CONGESTION  OF  THE  SPLEEN. 

Chronic  Passive  Congestion  of  the  spleen  occurs  where  there  are  dis- 
turl)ances  of  the  portal  or  of  the  splenic  circulation.  This  is  met  with 
in  cirrhosis  and  more  rarely  in  syphilitic  changes  in  the  liver,  from 
monolocular  or  multilocular  echinococcus  cysts,  and  from  hyperemia 
of  the  liver.  It  may  occur  from  emphysema,  cirrhotic  conditions,  or 
advanced  tuberculous  lesions  in  the  lungs,  and  from  acquired  or  con- 
genital heart  lesions.    When  the  spleen  is  enlarged  from  chronic  passive 


DISEASES  OF  THE  SPLEEN  847 

congestion  the  liver  is  too,  except  in  those  rare  conditions  where  there 
is  disturbance  of  the  splenic  circulation  alone. 


SPLENITIS  AND  PERISPLENITIS. 

Inflammation  of  the  spleen  may  occur  from  extension  of  a  neighbor- 
ing inflammatory  process.  The  diagnosis  is  uncertain,  but  an  enlarged 
spleen,  pain  in  the  splenic  region,  and  the  pre-existing  inflammation 
are  the  parts  to  be  considered.  Perisplenitis  may  result  from  peritonitis, 
trauma,  hemorrhagic  infarcts,  syphilis,  or  tuberculosis.  The  spleen 
is  generally  enlarged.  The  diagnosis  is  made  by  feeling  the  friction  rub. 
It  is  less  certain  when  the  friction  sound  is  heard,  as  it  may  be  confused 
with  pleurisy.  If  it  is  heard  louder  below  than  above,  and  especially 
if  it  is  heard  better  with  the  stethoscope  at  the  edge  of  the  ribs  than  over 
the  chest  wall,  one  may  think  of  perisplenitis.  In  chronic  perisplenitis 
there  may  be  adhesions  and  the  spleen  is  no  longer  movable.  There 
is  more  frequently  a  chronic  thickening  without  adhesions. 

Floating  spleen  may  occasionally  be  met  with  as  a  congenital  condition. 
The  diagnosis  is  usually  easy  if  abdomen  is  sufficiently  relaxed  to  admit 
of  satisfactory  palpation.  There  is  tympany  over  ninth  to  eleventh  ribs. 
The  spleen  is  felt  elsewhere,  generally  under  the  left  hypochondrium, 
but  it  may  be  as  low  as  the  pelvis.  The  spleen  may  be  recognized  by 
the  shape,  and  if  there  are  no  adhesions  may  be  pushed  back  in  place. 
Care  must  be  taken  to  differentiate  fecal  masses  in  the  colon  and  tumors 
of  the  same  size.  The  splenic  dulness,  together  with  palpation  of  the 
spleen  in  its  normal  position,  settles  the  matter.  The  fecal  masses  may 
be  removed  by  purgatives.  A  floating  spleen  may  be  enlarged  and 
cause  trouble  in  diagnosis.  Additional  spleens  may  often  be  present, 
but  are  rarely  large  enough  to  palpate.  It  may  be  extremely  difficult  at 
times  to  tell  a  floating  spleen  from  a  tumor  of  the  kidney. 


PRIMARY  SPLENOMEGALY. 

This  is  a  rare  form  of  enlargement  of  the  spleen,  first  described  by 
Gaucher,  which  comes  on  without  any  apparent  cause.  The  changes 
in  the  spleen  consist  in  a  hyperplasia  of  the  endothelial  cells.  There 
may  also  be  changes  in  the  retroperitoneal  and  mesenteric  lymph  nodes 
and  an  increase  in  the  connective  tissue  in  the  liver.  The  disease 
begins  in  early  childhood,  from  the  second  to  the  seventh  year,  and  there 
are  slow  but  progressive  changes.  The  enlargement  of  the  liver  is 
always  secondary  to  the  splenic  enlargement,  and  never  to  the  same 
extent.  In  addition  there  is  a  simple  anemia,  softening  of  the  gums 
with  oozing  of  blood,  epistaxis,  subcutaneous  hemorrhages,  and  occa- 
sionally icterus.  The  symptoms  are  those  referable  to  the  splenic 
enlargement.  There  is  pain  in  the  abdomen,  disturbances  of  the  func- 
tions of  stomach  and  intestines  and  sometimes  dysuria.    There  may  be 


848    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

dvspnea.  (  r;mij)s  in  the  k'i;s  liavr  \)vvu  noted,  'riic  (liscasc  may  last 
for  years,  the  spleen  eventually  jM-aetieally  lillini:,'  the  abdomen.  Bovaird^ 
has  reported  cases  and  discussed  the  subject  fully. 


NEW-GROWTHS. 

These  arc  rare  in  the  spleen  durin<:;  early  life,  and  may  ])e  difficult  to 
ditferentiate  from  simple  hypertrophy.  If  the  spleen  has  an  uneven 
surface,  especially  if  there  are  {)rominent  nodides,  a  new-^jrowth  may 
be  present.     This  may  be: 

(a)  Tuherculosis.  Where  there  is  tuberculosis  elsewhere  in  the  body. 
The  commonest  form  of  nodular  spleen  in  children. 

(6)  Sarcoma  may  be  primary  or  occur  as  metastasis.  A  rare  con- 
dition. 

(c)  Carcinonw  is  very  rare,  but  has  l)een  reported.  Carcinoma  is 
fovmd  elsewhere  in  the  body. 

{(l)  Syphilitic  irrccjularitics  disappear  or  improve  on  treatment,  and 
there  are  usually  other  evidences  of  the  disease. 

(p)  Ci/sfic  tumorfi  may  result  from  hemorrhafje  and  are  of  <i;reat 
rarity  in  children.  They  contain  cholestcrin,  lecithin,  and  blood-color- 
ing matter. 

(/)  Parasites  (echinococcus)  have  been  reported  in  Europe,  but  not 
in  America  to  my  knowledge. 

'  American  Journal  of  the  Medical  Sciences,  October,  1900. 


CHAPTER   XXXIV. 

THE  ADRENALS— ADDISON'S  DISEASE— CRETINISM— DIABETES 

MELLITUS. 

THE  ADRENALS. 

The  study  of  the  adrenals  has  been  much  neglected  in  infancy.  In 
early  life  they  are  relatively  larger  than  in  adults.  In  infants  dying 
with  severe  general  congestion  they  are  markedly  enlarged  and  may 
contain  hemorrhages.  In  the  reverse  type,  where  the  infants  seem 
bloodless  and  the  tissues  anemic,  the  adrenals  are  small  and  contracted. 

Hemorrhage  into  the  Adrenal. — This  occurs  possibly  as  a  separate 
disease.^  Arnaud  has  described  three  classes  of  symptoms  occurring 
with  hemorrhage  into  the  adrenal:  asthenic,  peritoneal,  and  nervous. 
It  occurs  in  the  course  of  gastroenteric  infection;  it  is  common  in  the 
newborn;  it  may  occur  in  any  disease  where  there  is  stagnation  of  the 
blood  or  congestion,  as  in  acute  or  chronic  diseases  of  the  lungs,  heart 
disease,  and  convulsions.  It  may  be  seen  in  septicemia,  pyemia,  acute 
miliary  tuberculosis,  and  the  various  toxemias.  Congenital  syphilis 
has  also  been  mentioned,  but  seems  unimportant.  Traumatism  may 
be  a  cause  and  the  so-called  blood  diseases,  as  scurvy,  may  play  a  part. 

The  whole  gland  may  be  transformed  into  a  blood  sac  with  extrava- 
sation into  the  surrounding  tissue.  There  may  be  hemorrhage  into 
the  medulla  of  the  gland,  while  the  cortex  remains  free  or  nearly  so,  as 
there  may  be  scattered  hemorrhages  into  the  gland  substance,  chiefly 
in  the  medulla. 

Symptomatology. — -There  may  be  symptoms  of  an  acute  infection. 
In  this  there  is  an  acute  onset,  generally  in  a  previously  healthy  infant. 
There  may  be  vomiting,  diarrhea,  and  in  a  few  hours  a  petechial  or 
purpuric  eruption  may  appear  over  the  child.  There  is  usually  a  tem- 
perature of  from  101°  to  105°  F.  The  child  collapses  and  dies.  The 
diagnosis  is  usually  made  of  one  of  the  eruptive  fevers.  Many  cases 
have  been  in  unvaccinated  children  and  have  been  called  smallpox. 
(See  Purpura  Fulminans,  p.  831.) 

A  second  class  of  cases  is  seen  where  there  is  purpuric  rash,  but  where 
there  is  nothing  to  suggest  an  acute  specific  fever.  A  third  class  cannot 
be  recognized  clinically,  occurring  as  it  does  in  the  course  of  some  pre- 
existing disease,  as  in  pneumonia.  This  is  only  to  be  made  clear  at 
autopsy. 

Lastly,  hemorrhages  in  the  adrenal  are  found  in  the  hemorrhagic 
diseases  of  the  newborn. 

1  Dudgeon,  American  Journal  of  the  Medical  Sciences,  February,  1904. 
54  (849) 


S50     DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 


ADDISON'S  DISEASE. 

Addison's  Disease  is  chanu-terized  in  children  hy  the  same  bronzing 
of  the  skin  and  progressive  cachexia  that  are  fonnd  in  achdts.  Tiie  lesion 
in  nearly  all  cases  is  a  tuberculosis  of  the  adrenal,  but  a  few  instances 
have  been  reported  where  the  lesion  wa,s  a  malignant  growth  in  the 
gland.  It  has  also  been  noted  that  there  may  be  tubereulous  lesions 
of  the  adrenal  without  any  symptoms.  Th(>re  are  usually  tuberculous 
deposits  elsewhere  in  the  body,  the  lungs  and  the  lymph  nodes  being 
most  frequently  affected.  There  are  changes  in  the  abdominal  sympa- 
thetic nerves.  The  pigmentation  of  the  skin  is  due  to  deposits  of  pigment 
in  the  Alalpighian  layer. 

The  disease  becomes  rarer  the  younger  the  age  of  the  child.  Under 
five  years  of  age  it  has  been  seen  occa,sionally,  but  is  almost  unknown. 
A  congenital  case  has  been  reported.  After  eleven  it  is  seen  more 
frecjuentlv.  Boys  are  affected  slightly  oftener  than  girls.  In  21  cases 
collected  by  Comby,  12  were  in  boys  and  9  in  girls. 

Symptomatology. — The  onset  is  usually  gradual.  There  may  or  may 
not  be  tuberculosis  of  lungs,  lymph  nodes,  or  of  other  organs.  There  is 
progressive  weakness,  with  symptoms  of  stomach  trouble.  There  may 
be  vomiting  and,  in  some  cases,  diarrhea.  In  some  cases  lumbar  pains 
or  vague  pains  in  the  limbs  are  complained  of.  There  may  be  colic  or 
headaches.  As  the  disease  progresses  the  ])atient  becom(>s  cachectic. 
The  most  marked  thing  is  the  pigmentation  of  the  skin.  This  may  be 
partial  or  general.  The  color  is  a  dirty  yellow,  which  becomes  darker. 
The  exposed  parts  of  the  body,  face  and  hands,  and  the  parts  contain- 
ing pigment,  such  as  the  areola  of  the  breasts,  the  external  genitalia, 
the  groins,  and  axilhie,  may  be  very  dark  or  even  almost  l)lack  in  color. 
The  hair  may  change  color.  There  are  usually  pigmented  patches  in 
the  mucous  membranes.  The  patient  becomes  weaker  and  weaker, 
antl  fever  may  develop.  The  pulse  becomes  rapid  and  filiform  and  the 
respirations  are  increased.  Many  of  the  patients  die  of  tuberculosis  of 
the  lungs,  others  from  asthenia.  At  the  time  of  death  there  may  be 
convulsions,  coma,  or  syncope. 

Diagnosis. — This  is,  as  a  rule,  not  difficult  if  the  case  is  well  developed. 
The  symptom-complex  of  progressive  weakness,  pigmentation  of  the 
skin,  the  weak  and  rapid  pulse,  and  the  digestive  disturbances  serve  to 
differentiate  it  from  other  conditions.  One  shoukl  bear  in  mind  the 
pigmentation  from  arsenic.  In  this  the  use  of  the  drug  can  gener- 
ally be  elicited.  INIalarial  cachexia  may  be  distinguished  by  the  his- 
tory of  exposure,  the  parasite  in  the  l)lood  in  many  cases,  the  enlarged 
spleen  and  the  effect  of  cjuinine.  The  presence  of  bile  in  the  urine 
serves  to  differentiate  icterus.  The  bronzing  from  exposiu'e  may 
resemble  it  cjuite  closely  as  to  the  arrangement  of  the  color  of  the  skin, 
but  the  general  health  is  usually  good. 

Prognosis  is  always  bad.  There  have  been  some  cases  reported  as 
cured,  but  with  our  present  means  of  treatment  this  is  not  to  be  expected. 


CRETINISM  851 

Treatment. — This  consists  in  good  general  hygiene,  proper  care,  and 
regulation  of  the  diet.  Cod-liver  oil  is  most  highly  recommended  for 
its  nutritive  value.  Adrenalin  may  be  tried.  Of  the  1 :  1000  solution 
from  0.06  to  0.03  c.c.  (1  to  5  min.)  or  even  more  may  be  given.  It  has  not 
been  used  long  enough  to  state  anything  about  the  results.  Feeding  with 
adrenals  may  be  tried  in  place  of  the  adrenalin  if  desired.  The  glands 
may  be  given  raw  or  nearly  so,  on  bread  or  toast.  A  glycerin  extract  may 
be  used.  Tablets  of  the  dried  gland  are  also  sold.  One  gland  may  be 
given  once,  twice,  or  three  times  a  day.  From  one-quarter  to  a  whole 
tablet  may  be  given  at  a  time.  The  effect  in  all  cases  should  be  care- 
fully watched,  and  the  dose  regulated  accordingly. 


CRETINISM. 

Cretinism  is  a  *' chronic  affection  characterized  by  disturbance  of 
growth  of  the  skeleton  and  soft  parts,  a  remarkable  retardation  of 
development,  an  extraordinary  disproportion  between  the  different  parts 
of  the  body,  a  retention  of  the  infantile  state,  with  a  corresponding  lack 
of  mental  progress." 

Endemic  cretinism  has  been  known  for  a  long  while.  In  certain 
mountainous,  limestone  districts,  as  in  parts  of  Switzerland,  there  are 
frequently  seen  peculiar  dwarfs,  of  short  stature,  short  arms  and  legs, 
with  a  myxedematous  condition  of  the  subcutaneous  tissue.  The 
mentality  is  exceedingly  low.  In  a  rather  large  percentage  (60  per  cent.) 
there  is  a  goitre.    Most  of  these  endemic  cretins  die  before  thirty. 

Sporadic  cretinism  is  a  similar  condition  met  with  all  over  the  world. 
The  cause  is  unknown.  The  cretin  is  an  individual  whose  growth  has 
been  retarded.  Mentally  they  are  idiots  and  physically  dwarfs,  with 
the  characteristics  described  below. 

Usually  there  is  only  one  cretin  in  a  family,  the  other  children  being 
perfectly  normal.  In  some  instances  there  have  been  more  than  one 
in  the  same  family. 

Pathology. — The  condition  is  due  to  a  lack  of  or  insufficiency  of  the 
internal  secretion  of  the  thyroid  gland.  There  may  be  an  absence  of 
the  thyroid,  an  atrophy  of  it,  or  there  may  be  a  goitre.  This  last  is  not 
very  frequent  in  sporadic  cretinism.  In  Osier's  60  cases  it  was  present 
in  7.  The  changes  may  be  congenital  or  may  develop  after  an  acute 
infectious  disease.  Cases  have  followed  measles  and  typhoid  fever.  In 
these  there  is  an  atrophy  of  the  thyroid,  apparently  due  to  some  poison 
produced  by  the  acute  infection. 

There  is  a  lack  of  development  on  the  part  of  the  entire  body.  The 
child  is  dwarfed.  The  ossification  of  the  bones  goes  on  very  slowly 
and  imperfectly.  There  is  in  the  subcutaneous  tissue  a  substance  giving 
the  reaction  of  mucin  which  causes  the  edematous  appearance;  hence 
the  name  myxedema  which  is  given  to  the  case  occurring  in  adult  life. 

An  interesting  class  of  cases  seen  in  older  individuals  is  that  follow- 
ing the  operation  for  the  removal  of  the  thyroid.    Where  this  has  been 


852     DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

('()iiij)lc'to  a  iny\c'(l(>niat()U.s  condition  lias  supfrvoncd.  A  small  part  of 
the  thyroid  k'ft  Ix-hind  will  piwcnt  this.  Tlu'  acute  synij)tonis  coming 
on  a  few  tlays  after  operations,  consisting  of  tctany-like  convulsions,  great 
prostration,  and  death,  are  due  to  the  removal  of  the  parathyroids,  small 
glandular  bodies  near  or  on  the  thyroid  which  evidently  play  an  important 
part  in  the  animal  economy. 

Mvxedcma  can  be  produced  experimentally  in  animals  by  r(>moving 
the  thyroids.  Sporadic  cretinism  may  be  regarded  as  infantile  or 
juvenile  myxedema. 

In  some  instances  the  function  of  the  gland,  while  impaired,  is  not 
entirelv  destroyed.  This  may  give  rise  to  symptoms  which  have  the 
api)carance  of  mild  myxed(Mna,  and  these  have  been  described  by 
French  and  Belgian  writers  as  niyxccdcnic  fritste. 

Symptomatology. — The  symptoms  may  come  on  at  any  time.  Cases 
have  been  noted  a. few  wrecks  after  birth.  In  others  about  the  first  or 
second  year.  These  may  have  escaped  notice  until  a  lack  of  develop- 
ment calls  attention  to  the  condition.  Other  cases  may  a])pear  later, 
and  these  cither  follow  some  acute  infectious  tlisease  or  some  unknow^i 
cause. 

The  cases  seen  in  early  infancy  may  be  difficult  to  recognize  unless 
they  arc  very  ])i()nounce(l.  The  infant  is  sluggish  and  torpid  and  does 
not  pay  attention  to  anything.  The  temperature  is  below  normal  and 
the  body  is  easily  chilled.  It  feels  cold  to  the  touch.  The  expression 
is  not  suggestive  of  healthy  infancy.  The  eyes  are  puffy  and  the  tongue 
mav  protrude  through  the  op(Mi  mouth.  The  tongue  itself  is  thick  and 
unsha})ely.  The  cry  is  hoarse  and  guttural.  The  abdomen  is  ])r()minent. 
As  time  goes  on  these  characteristics  become  more  and  more  pronounced. 

The  cases  seen  about  two  years  of  age  may  be  told  at  a  glance.  They 
have  a  very  characteristic  appearance.  They  are  shorter  than  normal 
children  of  the  same  age.  The  body  is  pro])ortionately  larger  than 
the  extremities,  and  the  head  seems  too  large  for  ])()th.  The  fore- 
head is  low  and  the  fontanels  open.  The  fontanels  may  remain  open 
until  ten  or  twelve  years  of  age  or  even  later  than  that.  The  hair  is 
coarse  and  straight.  The  face  is  very  striking  and  w^ell  illustrated  in 
Plate  XXVI.  The  expression  is  pig-like.  The  base  of  the  nose  is 
broad  and  the  eyes  wide  apart.  The  eyes  are  slit-like,  reminding  one  of 
pigs'  eyes;  the  eyelids  are  puffy.  The  eyebrows  are  scanty  or  wanting. 
Tlie  cheeks  are  large  and  sag.  The  lips  are  prominent;  the  tongue  is 
thick  and  usually  protrudes  through  the  half-open  mouth.  There  is  apt 
to  be  drooling.  The  teeth  are  eru])ted  late  and  arc  apt  to  decay  early. 
The  neck  is  short  and  the  head  seems  set  directly  on  the  trunk.  The 
arms  and  legs  are  short  and  misshapen.  The  patients  assume  a  squatty 
attitude  and  generally  have  more  or  less  kyphosis  or  lordosis.  The 
hands  are  short  and  spade-like,  with  broad,  prominent  hypothenar 
eminences.  The  genitalia  are  edematous-looking  and  remain  unde- 
veloped throughout  life  in  the  untreated  cases.  The  abdomen  is  prom- 
inent and  pendulous.  The  skin  is  coarse  and  rough,  sallow  and 
waxy.    There  is  a  tendency  to  eczematous  skin  eruptions.    The  entire 


PLATE  XXVI. 


sporadic  Cretinism.     Child  fifteen  months  of  age.     (Koplik.) 


CRETINISM  853 

body  has  an  edematous  appearance,  but  there  is  no  pitting  on  pressure. 
The  thyroid  may  be  absent  and  there  may  even  be  a  depression  in  its 
place.  In  the  older  cases  there  may  be  subcutaneous  fatty  tumors 
which  are  usually  symmetrical  and  most  frequently  just  above  the 
clavicles  or  above  the  shoulders.  Many  cretins  are  deaf-mutes,  but  if 
they  talk  the  voice  is  hoarse  and  guttural.  There  is  usually  marked 
constipation.  If  the  cretin  walks  at  all  he  is  late  in  learning,  and  he 
may  be  five  or  six  years  old  before  he  makes  any  effort.  When  he  does 
walk  the  gait  is  uncertain  and  of  a  waddling  character.  Cretins  are 
sluggish,  lethargic  individuals,  who  lead  a  rather  vegetable  type  of 
existence.     They  may  have  epileptiform  seizures. 

As  time  progresses  all  these  features  become  more  pronounced. 
They  remain  short  and  undersized,  and  when  the  disease  has  begun 
in  early  infancy  a  cretin  of  twenty  may  have  the  appearance  of  a  child 
of  three  or  four,  or  even  younger.  Their  mental  development  is  about 
equal  to  that  of  children  whose  age  they  resemble.  They  talk  but  little, 
if  at  all,  and  are  child-like  in  all  particulars.  I  know  of  a  cretin  of 
fifty-eight,  the  size  of  a  small  girl,  who  still  sits  on  the  floor  and  plays 
with  her  dolls. 

The  partially  developed  cases,  the  myxoedeme  jrusie  of  the  French, 
may  be  less  easy  to  recognize.  A  child  late  in  teething,  with  an  open 
fontanel,  who  ceases  "to  get  on,"  should  always  suggest  cretinism. 
The  skin  becomes  lax,  the  child  gets  fat  and  flabby,  and  the  abdomen 
prominent.  The  cretin  appearance  may  be  more  or  less  marked.  The 
loss  of  vivacity  is  striking. 

Diagnosis. — This  is  easy  as  a  rule.  A  child  with  an  open  fontanel 
later  than  eighteen  months,  the  delayed  dentition  or  any  of  the  other 
features  described,  should  suggest  the  disease.  Once  having  seen  a 
case,  or  a  photograph  of  one,  it  is  difficult  to  mistake  a  well-developed 
case  of  cretinism.  The  differential  diagnosis  is  from  several  other 
conditions. 

Mongolian  Idiocy. — This  most  nearly  resembles  cretinism.  There 
is  a  distinct  Mongolian  type  of  face ;  they  are  dwarfed  and  of  a  low  grade 
mentally.  These  cases  are,  as  a  rule,  much  more  sprightly  than  cretins. 
They  have  no  myxedematous  condition  of  the  subcutaneous  tissues 
and  are  more  shapely  than  the  cretin.  The  hands  may  show  a  crooking 
of  the  little  finger. 

Infantilism. — Mild  grades  of  cretinism  might  be  confused  with 
infantilism,  but  not  marked  cases.  Infantilism  is  a  "morphological 
syndrome  characterized  by  the  preservation  in  the  adult  of  the  exterior 
form  of  infancy  with  the  non-appearance  of  the  secondary  sexual 
characters."  The  following  is  a  translation  of  a  French  description 
of  the  condition  (Lamy):  "The  face  is  rounded  and  chubby,  the  lips 
prominent  and  plump,  the  nose  poorly  developed,  the  face  smooth, 
the  skin  fine  and  of  a  clear  color,  the  hair  fine,  the  eyebrows  and  lashes 
sparse.  The  trunk  is  long  and  cylindrical.  The  abdomen  is  somewhat 
prominent,  the  arms  and  legs  plump  and  tapering  from  the  trunk  to 
the  extremity.    A  layer  of  adipose  tissue  surrounds  the  body  and  masks 


854    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

the  liony  and  muscular  prominences.  The  genital  organs  arc  rudi- 
mentary. There  is  an  absence  of  hair  on  the  pubes  and  axilla.  The 
voice  is  shrill  and  piercing.  The  larynx  is  j)oorly  developed  and  the 
thvroid  small."     Infantilism  may  be  seen  in  hereditary  syphilis. 

Rickets. — The  delayed  dentition  and  the  open  fontanel  might  lead 
to  confusion  by  a  careless  observer,  but  the  rachitic  child  is  much  more 
alert  and  the  skin  is  more  often  moist  than  dry  (see  p.  321). 

Achondroplasia. — This  is  a  curious  form  of  (hvarfism,  called  also 
Chondrodystrophy,  usually  congenital,  but  exceptionally  appearing  a 
few  years  after  birth.  The  majority  of  cases  are  born  dead  or  die  soon 
after  birth,  and  very  few  reach  maturity.  They  are  frequently  seen  in 
variety  shows  and  museums.  The  condition  was  descril)ed  by  the  early, 
writers  as  Fetal  Rickets  or  Fetal  iMyxedema.  Pathologically  the  disease 
is  a  dystrophy  of  the  epiphyseal  cartilages.  P.  Marie  called  attention  to 
the  distinguishing  features  of  the  condition  a  few  years  ago.  Achondro- 
plasia is  usually  easily  recognized.  These  patients  have  very  large  heads 
and  very  short  arms  and  k\g.s  (Figs.  173,  174  and  1 75).  The  humerus  and 
femur  are  apt  to  be  (juite  short.  The  trunk  and  thorax,  wliile  small,  are 
normal.  The  long  bones  show  considerable  hypertrophy  at  the  epiphyses, 
but  the  shafts  of  the  bones  are  normal.  The  hands  are  peculiar,  short, 
and  spade-like.  They  have  been  called  "  trident  shaped,"  from  the  devia- 
tion of  the  htst  two  phalanges.  The  first  phalanges  are  close  together. 
The  intellect  is  usually  about  that  of  children  of  the  same  height  and 
they  are  exceedingly  mischievous.  Sometimes  they  may  have  fair  minds. 
Unlike  other  dwarfs,  they  are  well  developed  sexually  and  have  strong 
sexual  instincts.  They  are  sometimes  mistaken  for  cretins,  with 
whom  they  have  nothing  in  common,  but  arc  easily  distinguished 
by  the  above-mentioned  points.  From  rickets  the  points  of  diagnosis 
are  apparent,  and  the  two  diseases  are  not  associated. 

Prognosis. — The  prognosis  in  untreated  cases  of  cretinism  is  bad. 
They  remain  hopeless  idiots.  Death  generally  takes  place  from  some 
intercurrent  affection  before  thirty  years  of  age,  but  occasionally  they 
live  much  longer.  With  treatment  by  means  of  the  internal  admin- 
istration of  the  thvroid  gland  the  outlook  is  very  good  in  all  cases  seen 
young.  After  puberty  the  results,  while  fairly  satisfactory,  are  not  nearly 
so  brilliant.  After  adult  age  has  been  attained  comparatively  little 
benefit  is  derived  from  treatment,  but  even  then  the  results  may  at 
times  be  striking.  This,  of  course,  applies  only  to  cretins  who  have 
been  so  from  infancy  and  not  to  cases  of  myxedema  acquired  in  late 
life.     In  these  latter  cases  the  results  of  treatment  are  very  satisfactory. 

Treatment. — ^The  treatment  of  cretinism  is  one  of  the  most  brilliant 
results  of  modern  medicine.  The  credit  belongs  to  a  large  number  of 
workers,  chief  among  whom  may  be  mentioned  the  physicians  Gull 
and  Ord,  who  described  the  adult  type  of  myxedema;  the  surgeons 
Kocher  and  the  Reverdins  for  experimental  and  operative  work,  and 
the  physiologists  Schiff,  Horsley,  and  von  Fiselsberg  for  the  direct 
demonstrations  of  the  possibilities  of  treatment.  If  thyroid  gland  is 
supplied  to  the  body,  the  effect  is  wonderful.    Experimentally  the  living 


CRETIXISM 


855 


gland  was  first  grafted  into  the  body;  later  the  patients  were  fed  on  the 
fresh  glands,  and  then  the  dried  gland  was  used  as  being  more  con- 
venient for  administration.     The  desiccated  thyroids  are  now  supplied 


Ftg. 173 


Fig. 174 


Achondroplasia  (chondrodystrophy). 


in  tablet  form  by  several  manufacturing  chemists.  The  tablets  each 
represent  0.324  gm.  (5  gr.)  of  the  fresh  gland  of  the  sheep.  The  dose 
should  be  small  at  first  and  gradually  increased.  For  infants  it  is  well 
to  begin  with  a  quarter  of  a  tablet,  three  times  a  day.  If  no  effect  is 
noted^the  dose  may  be  gradually  raised  to  0.324  gm.  (5  gr.)  three  times 


856    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 


Fig. 175 


a  (lav,  and  wIkmi  this  is  not  efrective  two  or  oven  throe  tablets  may  he 
given  as  a  dose.    If  the  dosage  is  too  great  unpleasant  symptoms  oeeur; 

fever,  rapid  pulse,  and  flushing  are  the 
principal  ones.  Should  these  occur  the  dose 
should  !)(>  (Hminished.  It  is  well  to  break 
the  treiitment  occasionally  and  give  the 
patient  a  few  days'  rest. 

The  effect  of  the  treatment  is  marvellous. 
After  a  month  or  six  weeks'  time  there  is 
a  loss  of  weight  an<l  the  myxedematous 
appearance  gradually  disappears.  The 
expression  becomes  more  natural,  the  face 
loses  its  puffy  appearance,  the  palpebral 
orifice.*?  become  wider,  the  abdomen  de- 
creases in  size,  and  the  child's  figure 
assumes  the  shape  of  a  normal  child 
The  hair  and  skin  become  more  natural 
in  appearance.  In  younger  infants  teeth- 
ing goes  on  rapidly.  In  old(>r  individuals 
in  whom  the  milk  teeth  have  not  been 
shed  there  is  a  replacement  of  these  by 
the  permanent  teeth.  The  growth  in 
height  is  very  striking;  from  four  to  (Mght 
inches,  and  even  more,  has  been  noted 
in  a  year.  The  mental  change  is  also 
marked.  The  change  is  (greatest  in  young 
cretins,  but  the  older  ones  may  also  be 
benefited.  The  child  begins  to  talk,  and 
if  it  talked  Ix^fore  it  rapidly  acquires  a 
lar<>;(>r  vocabularv.  The  whole  beinjj  is 
transformed  from  the  condition  of  a  veg- 
etable to  that  of  a  living  human  being. 

The  treatment  shoukl  be  continued 
until  all  traces  of  the  myxedematous 
condition  have  disappeared,  and  until  natural  growth  has  been  estab- 
lished. After  that  time  very  small  doses  should  be  continued  through- 
out life,  one  or  two  5-grain  tablets  a  week  seem  to  be  sufficient  to 
keep  the  individual  in  good  condition.  This  should  be  insisted  upon 
when  taking  charge  of  a  case.  The  treatment  may  be  stopj^ed  for  a 
month  or  six  weeks,  but  if  it  is  discontinued  for  any  longer  the  symptoms 
begin  to  return.  The  ciiild  becomes  listless  and  begins  to  show  other 
symptoms  of  a  return  of  the  trouble. 


Achondroplasia.    (Case  of  Drs.  West 
and  Piper,  Archives  of  Pediatrics.) 


DIABETES  MELLITUS. 


Diabetes  Mellitus  is  characterized  in  children  by  the  same  symptoms 
as  seen    in    adults,  the   most  notable    being   the   glycosm'ia,  polyuria, 


DIABETES  MELLITUS  857 

increased  appetite,  increased  thirst,  and  the  progressive  loss  of  weight. 
It  must  be  borne  in  mind  that  diabetes  melHtus  is  manifested  by  a 
symptom-complex,  and  that  the  mere  presence  of  sugar  in  the  urine 
may  not  mean  diabetes. 

The  disease  is  rare  in  childhood,  but  probably  not  so  rare  as  was 
formerly  supposed.  Owing  to  the  carelessness  about  examining  the 
urine  of  young  children,  and  the  extreme  difficulty  in  securing  it  in 
some  instances,  the  disease  may  easily  be  overlooked. 

It  is  a  difficult  disease  to  study  in  children,  and  our  knowledge  of  the 
subject  is  based  on  comparatively  few  cases  and  on  fewer  autopsies. 

Etiology.  Frequency. — West,  in  700  cases,  gives  only  1  under  five 
years.  Ashby  and  Wright  mention  111  from  six  months  to  fifteen  years 
of  age.  Senator  found  1  case  in  5900  children  applying  at  a  polyclinic. 
Ebstein  found  1  in  694  children.  Pavy  in  1360  cases  of  diabetes  gives 
S  under  ten  years.  Seegen  in  800  cases  of  diabetes  gives  4  under  ten 
years.    Schmitz  in  600  cases  gives  5  under  ten  years. 

Age. — Orlofl^  mentions  7  cases  in  nursing  infants.  Undoubted  cases 
have  been  reported  as  early  as  four  months  of  age.  The  very  early 
cases,  from  foiu'teen  days  to  one  month,  are  supposed  to  be  lactosuria, 
as  they  recovered. 

Wegeli.  Leroux. 

0  to   1  year 1  case.  1  case. 

1  to   5  years .    26  cases.  23  cases. 

5  to  10      " 31      "  43      " 

10  to  15      " 42      "  71      " 

Sex. — In  adults  the  males  preponderate.  In  children  the  sex  influence 
seems  very  slight.  Males  are  slightly  more  often  affected  before  five 
years,  but  from  five  to  fifteen  years  the  sexes  are  about  equal,  or  if 
anything  a  slightly  larger  number  of  females  are  affected. 

Diabetes  is  frequent  in  Jews,  in  adults,  but  race  influence  apparently 
plays  but  little  part  in  children. 

Heredity. — There  is  a  strong  hereditary  tendency  to  the  disease.  Many 
instances  are  on  record  where  there  are  two  or  more  cases  of  diabetes 
in  the  child's  ancestors  or  family.  Of  the  other  diseases  mentioned  the 
neuropathic  tendency  and  gout  are  the  most  frequent.  Syphilis  and 
rheumatism    are    also   given   as    predisposing   causes. 

Exciting  Causes. — Blows  or  injuries  to  the  head  are  given  as  a  fre- 
quent exciting  cause.  Wegeli  mentions  11  out  of  108  cases  where  the 
diabetes  followed  trauma  of  the  head.  Blows  on  other  parts  of  the 
body  are  also  mentioned,  especially  the  spine,  back,  and  abdomen. 
Various  nervous  diseases,  such  as  tuberculous  meningitis,  chorea,  and 
epilepsy  are  sometimes  associated.  Cold  is  also  reckoned  as  a  causative 
factor.  The  influence  of  previous  diseases,  especially  the  infections, 
must  not  be  forgotten.  Too  much  sugar  and  starch  in  the  food,  par- 
ticularly when  there  is  an  hereditary  predisposition,  may  apparently 
bring  on  diabetes.  Stareh  indigestion  may  be  noted  in  some  children 
with  an  hereditary  tendency  to  diabetes. 

Pathology. — This  is  apparently  the  same  as  in  adults.  As  yet  the 
subject  is  not  at  all  clear.    The  morbid  anatomy  is  based  on  compara- 


858    DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

lively  few  autopsies.  Lesions  have  been  noted  in  the  floor  of  the  fourth 
ventricle  and  also  in  the  pancreas. 

Symptomatology. — This  is  the  same  as  in  the  adult.  There  are 
polvuria,  (^[lycoNuria,  increased  appetite,  and  increased  thirst. 

The  polyuria  is  (juite  constant.  The  child  may  recpiire  changing 
twenty  or  thirty  times  a  day.  When  the  urine  can  he  measured  it  varies 
between  1  and  5  litres,  although  cases  have  been  reported  where  in 
twcntv-four  hours  the  child  passed  the  remarkable  amount  of  10  litres. 
'I'hc  polyuria  is  more  marked  during  the  day  than  at  night.  Enuresis 
is  a  fre(|uent  symptom  and  one  which  should  always  lead  to  an  exami- 
nation of  the  urine.  Coming  on  in  a  child  who  has  previously  held  his 
urine  all  night  it  Ls  suggestive. 

The  appetite  is  usually  very  much  increased,  and  gastric  and  intestinal 
disturbances  are  frequent.  Diabetic  children  are  usually  constipated. 
The  gums  are  frecpiently  swollen  and  bleed  easily.  The  moutli  and 
tongue  are  usually  dry. 

The  thirst  Is  very  pronounced,  and  the  children  drink  or  attempt  to 
drink  any  fluid  in  sight. 

The  skin  becomes  dry  and  scaly  and  there  are  frecpient  eczematous 
diseases  or  furunculosis.  Pruritus  of  the  genitalia  is  common.  Edema 
may  be  seen  occasionally. 

The  children  waste  away,  and  if  the  disease  lasts  any  length  of  time 
they  become  veritable  skeletons.     They  lose  strength  as  well. 

Headache  is  frecjuent  and  they  complain  of  other  pains  and  neuralgias. 
The  patellar  reflexes  may  be  diminished  or  lost  altogether.  There  is  an 
alteration  in  the  child's  character.  Diabetic  children  become  irritable, 
cross,  capricioiLs,  and  later  on  they  may  become  apathetic.  Insomnia 
is  usually  })resent. 

The  sight  may  be  diminished  almost  to  blindness.  Von  Graefe  and 
others  have  reported  diabetic  cataracts  in  children. 

The  disease  frecjuently  comes  on  suddenly  in  young  people  and 
generally  runs  a  rapid  course.  .\s  a  rule,  it  is  a  cjuestion  of  weeks  or 
mcmths.  Cases  have  been  reported  where  death  ensued  twelve  days 
after  the  sudden  onset.  Kulz  gives  40  cases  as  follows:  10  lived  less 
than  three  months,  14  less  than  one  year,  and  the  others  lived  between 
one  and  four  years.  Death  usually  takes  place  from  pneumonia,  tuber- 
culosis, asthenia,  or  coma. 

Diabetic  Coma. — "^riiere  may  be  prodromes,  consisting  of  increased 
feebleness,  a  sweetish  chloroform-like  odor  of  the  breath,  and  diacetic 
acid  in  the  urine.  The  attack  may  come  on  with  vomiting  and  fliarrhea. 
The  child  becomes  apathetic  and  soon  loses  consciousness.  The  pupils 
are  fixed  and  equal  and  may  be  either  dilated  or  contracted.  The  knee- 
jerks  are  abolished.  The  rectal  temperature  is  g(>nerally  lowered, 
although  it  may  be  raised.  The  pulse  is  rapid  and  the  breathing  irregular. 
It  is  usually  of  a  deep,  sighing  character,  and  may  be  of  the  Cheyne- 
Stokes  type.     Sometimes  it  is  called  dyspneic  coma. 

The  child  becomes  algid  and  cyanotic  and  generally  dies  in  from 
eighteen  to  thirty-six  hours. 


DIABETES  MELLITUS  859 

The  Urine  in  Diabetes. — This  is  practically  the  same  as  in  adults. 
The  color  is  pale,  the  specific  gravity  raised  to  1.030  or  1.040,  but  this 
may  vary  greatly.  Proportionately  the  amount  of  glycogen  excreted 
is  rather  greater  in  children  than  in  adults.  There  may  be  albuminuria. 
There  may  be  acetonuria,  especially  a  few  weelcs  before  death,  and 
there  may  be  diacetic  acid  in  the  urine. 

Diagnosis. — This  is  made  as  in  adults,  on  the  presence  of  the  cardinal 
symptoms  and  by  the  examination  of  the  urine.  The  fermentation  test 
is  the  most  reliable. 

Care  should  be  taken  to  exclude  lactosuria,  which  is  occasionally  seen 
in  infants.  Alimentary  glycosuria  depending  on  the  ingestion  of  large 
amounts  of  sugar  should  be  excluded  by  cutting  down  the  sugar  in  the 
diet  to  a  minimum. 

By  the  following  test  Bremer  claims  to  be  able  to  make  the  diagnosis 
of  diabetes,  not  only  when  there  is  sugar  in  the  urine,  but  also  during 
the  sugar-free  intervals.  Moderately  thick  smears  of  blood  are  made 
on  the  glass  slides.  A  smear  of  normal  blood  is  made  as  a  control. 
These  are  heated  in  a  thermostat  up  to  135°  C.  When  cooled  they  are 
placed  back  to  back  in  a  tall  staining  dish  and  stained  two  minutes  in 
a  1  per  cent,  solution  of  Congo  red.  The  stain  is  washed  off.  Normal 
blood  takes  a  red  stain.  The  blood  of  diabetics  does  not  stain  at  all  by 
this  method. 

Prognosis. — The  prognosis  is  very  grave.  Death  is  the  rule.  Senator 
says  that  no  form  of  treatment  is  of  any  use.  In  28  cases  of  Wegeli's, 
all  personal  observation,  23  died  and  5  still  had  diabetes  at  the  time 
of  the  report.  The  reported  cures  are  usually  of  alimentary  glycosuria 
or  lactosuria,  or  are  only  remissions  in  the  real  disease,  which  appears 
later  if  the  case  is  followed. 

Treatment. — This  is  of  little  avail,  but  may  be  tried,  as  von  Noorden 
says  that  we  do  not  know  what  strict  diabetic  treatment  might  accom- 
plish, since  it  is  seldom  tried  in  children. 

Infants  may  be  allowed  to  nurse  at  the  breast.  Vichy  water  is  advised 
in  these  nursing  infants  by  French  writers.  A  teaspoonful  is  given  at 
each  nursing. 

Bottle-fed  babies  should  be  fed  on  modified  milk,  sweetened  with 
saccharin  or  mannite,  and  may  be  given  egg-water  or  beef-juice  and 
broths  as  well.  Cream  should  be  given  in  as  large  quantities  as 
possible. 

Infants  from  one  to  three  years  may  be  given  a  litre  of  milk  a  day, 
with  cream,  egg-water,  meat-juices,  broths,  raw  scraped  beef,  and 
purees  of  green  vegetables  (as  of  peas)  given  in  addition.  The  usual 
diabetic  breads  may  be  tried. 

In  older  children  the  diet  should  be  along  the  same  lines  as  that  recom- 
mended for  adults.  The  main  indications  are  to  keep  up  the  patient's 
strength,  and,  if  possible,  to  increase  it  by  giving  food  which  can  be 
utilized  by  the  body  and  to  avoid  complications.  These  indications  are 
best  fulfilled  by  a  diet  consisting  of  a  carefully  balanced  mixture  of 
proteids  and  fats,  with  as  little  starchy  food  as  possible  and  no  sugar. 


860     DISEASES  OF  BLOOD,  LYMPHATIC  SYSTEM  AND  GLANDS 

In  scvore  cases  von  Noorden's  oatniral  cure  maybe  tried/  This  consists 
in  f^ivinj^  a  very  well  cooked  oatmeal  to  which  vegetable  albumins  or 
egg-albumen  and  butter  have  been  added.  It  is  given  every  two  hours, 
and  coffee  and  some  form  of  alcoholic  beverage  may  be  allowed.  Every 
week  or  ten  days  meat  and  vegetables  are  allowed  for  a  day  to  break 
the  monotony  of  the  diet.  Return  to  an  ordinary  diet  must  be  gradually 
made.  Remarkable  results  are  said  to  be  obtained  by  this  diet  in 
severe  cases.     It  is  not  useful  in  the  lighter  forms. 

Prophylactic  Diet. — In  diabetic  families  it  is,  perhaps,  a  good  thing 
to  limit  the  amount  of  carbohydrate  food.  It  is  a  (|uestion  whethcM'  this 
has  any  effect  in  diminishing  the  ])r()l)ability  of  the  individual's  develop- 
ing diabetes,  (iood,  sensible,  hygienic  living  should  be  insisted  upon, 
and  any  tendency  to  obesity  managed  by  diet  and  exercise. 

Medicinal  Treatment. — A  great  nianv  drugs  have  been  advised.  Opium, 
morphine  or,  preferably,  codeine,  give  the  best  results.  Bromide  of 
potassium  is  also  of  value  in  some  cases  and  antipyrin  useful  in  the 
extremely  nervous  patients.  Arsenic  has  been  recommended,  as  has 
nearly  every  drug  in  the  pharmacopeia.  liactophosjihate  of  lime  has 
recently  been  used  by  some  observers  with  r(>})uted  success. 

>  Friedenwald  and  Ruhriih.    American  Jonrnal  of  the  Medical  Sciences,  October,  1905. 


SECTION  XL 
DISEASES  OP  THE  NEEVOUS  SYSTEM. 

By  D.  J.  ilcCARTHY,  M.D. 


CHAPTER    XXXV. 

FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTE^I— CONVULSIVE 

DISORDERS. 

Methods  of  Examination. — The  ehcitation  of  symptoms  referable 
to  the  nervous  system  in  children,  and  especially  in  infants,  is  usually 
associated  with  some  difficulty.  As  a  general  rule,  it  is  necessary  to 
have  the  child  thoroughly  stripped.  Any  palsy,  atrophy,  or  deformity 
becomes  apparent  to  the  eye  of  the  examiner.  For  the  determination 
of  reflexes  it  is  also  quite  necessary  that  the  child  should  be  stripped 
and  as  far  as  possible  relaxed.  It  is  to  be  remembered  in  this  connec- 
tion that  in  the  Bahinski  reflex  extension,  instead  of  flexion  of  the  toes, 
when  the  foot  is  tickled,  a  pathological  condition  in  the  adult  and  even 
in  the  child  after  it  has  begun  to  walk,  is  a  normal  phenomenon  in  the 
infant. 

Reflexes. — The  normal  plantar  reflex  of  the  walking  child,  as  in  the 
adult,  is  a  marked  flexion  and  adduction  of  the  toes  when  the  plantar 
surface  of  the  foot  is  irritated  by  slowly  drawing  a  blunt  point  along 
the  outer  or  inner  surface  of  the  sole.  The  ankle  should  be  firmly  held 
by  the  left  hand  and  the  knee  should  be  flexed  before  attempting  to 
elicit  this  symptom.  The  other  reflexes  of  importance  to  be  considered 
in  the  diagnosis  of  diseases  of  the  nervous  system  in  children  are  as 
follows : 

The  Knee-jerk. — This  is  obtained  in  young  children  only  with  diffi- 
culty. It  is  quite  necessary  to  have  the  patellar  tendon  in  a  condition 
of  slight  tension  and  to  have  the  attention  of  the  child  distracted,  and 
even  then  in  some  children  it  is  only  after  repeated  efforts  that  this 
phenomenon  can  be  demonstrated. 

The  Achilles-jerk. — This  is  best  obtained  by  ha^^ng  the  child  in  a 
kneeling  position  and  then  gi\'ing  a  slight  tap  with  the  percussion  ham- 

(861) 


862  DISEASES  OF  THE  XEKVOUS  SYSTEM 

iiicr  at   thr  insertion  of  the   Achilles  tendon.     This  reflex  is  usually 
()l)taine(l  without  much  difficulty. 

The  Biccps-jrrli. — The  arm  oi  the  child  should  he  held  relaxed  and 
in  a  Hexed  position  in  the  arm  of  the  examiner.  The  thumb  is  placed 
over  the  biceps  tendon  and  a  slight  taj)  of  the  hammer  on  the  thumb 
produces  a  reaction  in  the  biceps  which  can  be  easily  felt  by  the  j)al- 
])atin(;  thumb. 

The  Triceps-jerk. — The  arm  should  be  flexed  and  allowed  to  hang 
loose  over  the  arm  of  the  examiner;  a  slight  tap  is  then  given  at  the 
insertion  of  the  triceps  tendon. 

The  Chin-jerk. — ^This  is  obtained  by  a  slight  tap  directly  on  the  chin 
or  on  a  flnger  of  the  examiner  held  against  the  relaxed  chin;  a  sudden 
jerk  of  the  jaw  is  frecjuently  but  not  always  obtained. 

The  Cremasieric-jerk. — Scratching  the  iimer  surface  of  the  thigh 
results  in  a  contraction  of  the  scrotum  and  elevation  of  the  testicles. 

The  Superficial  Abdominal  Re flexe.^.— Scratching  the  skin  of  the 
abdomen  below  the  lower  margin  of  the  chest  results  in  a  sudden  nnis- 
cular  contraction  on  the  side  irritated. 

The  Eye  Reflexes. — The  reactions  of  the  pupil  to  light  and  to  accom- 
modation are  obtained  in  the  usual  manner. 

The  Examination  for  Sensation. — The  determination  of  disturbances 
of  sensation  is  obtained,  first,  by  watching  the  expression  of  the  child's 
face  when  a  comparative  test  of  the  application  of  a  pinpoint  is  made 
on  the  two  sides  of  the  body  or  between  an  area  of  normal  sensation 
and  the  affected  area;  second,  by  the  degree  of  muscular  retraction 
after  the  application  of  the  above  tests.  In  transverse  lesions  of  the 
cord  the  upper  limit  of  sensation  is  easily  determined  by  drawing  a 
sharp  point  alongthe  surface  of  the  skin, beginning  in  the  area  of  loss  of 
sensation,  and  noting  the  evidence  of  painful  impression  when  the 
normal  skin  is  approached. 

The  Electric  Examination. — In  making  an  examination  of  the  mus- 
cles for  reactions  of  degeneration  it  is  usually  necessary  in  young  chil- 
dren to  make  use  of  the  electrodes  without  current  so  as  to  accustom 
and  reassure  the  child  to  the  use  of  the  apparatus.  In  cases  where  it  is 
impossible  to  determine  the  formula  of  electric  degeneration,  the 
character  of  the  muscular  reaction  itself  is  as  valuable  in  determining 
the  presence  of  degenerative  atrophy.  The  normal  muscle  reacts  with 
a  (juick,  lightning-like  contraction;  the  degenerating  muscle  gives  a 
slow,  vermicular  reaction  in  ])roportion  to  the  extent  of  the  degenera- 
tion. 

The  Motor  Power. — Marked  loss  of  motor  power  is  manifest  on 
inspection  by  the  position  of  the  part  afl'ected,  the  fla^^cidity  of  the 
muscles,  and,  in  the  case  of  the  upper  extremity,  the  use  by  preference 
of  the  opposite  limb  in  simple  motor  acts. 

Lumbar  puncture  and  its  diagnostic  value  are  considered  under  Tuber- 
culous Meningitis,  p.  382 


FUNCTIONAL   DISEASES  OF    THE  NERVOUS   SYSTEM        S63 

FUNCTIONAL  DISEASES   OF  THE   NERVOUS   SYSTEM. 

CHOREIFORM  DISEASES. 

There  is  an  extensive  group  of  disorders  of  motion  occurring  in  child- 
hood, and  not  infrecjuently  extending  into  adult  life,  to  which  the  name 
of  Chorea  has  been  given.  Among  these  diseases  we  recognize  the 
following : 

1.  Acute  Chorea.     Chorea  Minor. 

2.  Chorea  Major. 

3.  Habit  Chorea.     Habit  Spasm. 

4.  Electric  Chorea. 

5.  Chronic  Progressive  Chorea.     Huntingdon's  Chorea. 

6.  Organic  Chorea.     Post-hemiplegic  Chorea.    Athetosis. 

Acute  Chorea. — This  disease,  also  called  Sydenham's  Chorea,  Chorea 
]\Iinor  and  Saint  Vitus'  Dance,  is  the  most  important  in  our  classifica- 
tion. It  is  almost  entirely  confined  to  childhood  and  characterized  by 
irregular,  involuntary,  purposeless  movements  affecting  the  voluntary 
muscles. 

Etiology .^ — It  occurs  with  much  more  frequency  in  the  female  sex 
and  is  especially  prone  to  affect  those  of  a  nervous  temperament.  It  is 
rare  in  infancy  and  after  puberty.  The  largest  number  of  cases  occur 
between  the  fifth  and  fifteenth  year.  Girls  of  the  lower  classes,  of  poor 
nutrition,  and  subject  to  the  strain  of  public-school  education  and  the 
worry  of  examinations  furnish  a  large  percentage  of  the  cases  studied. 
Of  the  infectious  fevers  rheumatism  plays  an  important  part  in  the 
etiology  of  this  infection.  The  acute  articular  inflammatory  type  of 
rheumatism  as  a  cause  of  chorea  is  comparatively  rare.  This  has 
occurred  in  only  two  cases  of  the  last  sixty  cases  coming  under  my  obser- 
vation. Vague  pains  about  the  joints,  with  occasionally  a  history  of  swell- 
ing and  tenderness,  occur  much  more  frequently.  There  is  still  a  third 
group  of  cases  presenting,  without  articular  or  pain  manifestations, 
an  acute  or  subacute  tonsillitis  or  pharyngitis.  If  all  the  above  mani- 
festations be  classed  as  rheumatic,  we  are  necessarily  forced  to  con- 
sider the  relation  between  rheumatism  and  chorea  as  very  close.  The 
French  writers  contend  that  there  is  a  very  close  relationship  between 
rheumatism  and  chorea;  the  German  school  on  the  ether  hand,  while 
admitting  a  certain  relationship,  do  not  go  so  far  as  the  former  The 
American  authorities  have  sometimes  taken  the  one  position  and  some- 
times the  other.  The  clinician  of  internal  medicine  is  more  hkely  to 
ascribe  a  close  casual  relationship  between  rheumatism  and  chorea  than 
the  specialist  on  ner\'ous  diseases,  because  the  physician  is  more  Hkely 
to  see  the  chorea  as  a  comphcation  of  rheumatism  than  to  see  the  isolated 
case  of  chorea,  and  to  investigate  the  relative  frequency  of  rheumatism, 
as  a  cause.  Poynton  states  that  chorea  is  "in  most  instances,  if  not  in  all, 
of  rheumatic  origin.^'  Of  the  five  hundred  and  fifty-four  cases  studied 
by  Osier,  fifteen  and  five-tenths  per  cent,  gave  the  history  of  rheuma- 


864  DISEASES  OF   THE  NERVOUS  SYSTEM 

tisin  in  the  family;  fifteen  and  ei«,dit-tentlis  per  eent.  ^nive  a  history  of 
arthritic  .swellinj^,  acute  or  subacute,  and  only  twenty-one  per  cent, 
as  a  maxiniuni  (rave  a  history  of  rheumatism  or  vague  pains  sometimes 
(Icsfrihed  as  rheumatic  in  various  parts,  but  not  associated  with  joint 
trouble.  Kaufman,  in  a  study  of  forty  cases,  gave  rheumatism  as  a  com- 
plication in  six  of  these.  As  an  example  of  what  these  statistics  mean, 
however,  in  one  of  the  cases  the  rheumatism  antedated  the  chorea  three 
years.  The  following  table  stiites  the  relationship  in  two  columns.  In 
the  first  column  the  percentage  is  that  of  an  antecedent  rheumatism. 
In  the  second  column  of  a  coincidental  rheumatism  compUcating  the 
chorea. 

Per  cent.  Per  cent. 

1.  Sturgos SO-.'i  4.45 

2.  Dickinson 2(5.75  7 

3.  Peacock 2S  7.6G 

4.  Owen 20  S 

5.  ORle 10 

In  many  of  the  articles  written  upon  these  subjects,  the  term  rheu- 
matism is  u.sed  in  such  a  general  way  to  express  vague  pains,  headache, 
etc.,  that  they  are  of  little  value  in  studying  the  true  relationship  be- 
tween rheumatism  and  chorea.  I  stated  above  the  presence  of  acute 
inflammatory  articular  rheumatism  was  only  two  cases  in  sixty.  These 
were  the  only  two  cases  which  presented  a  clinical  picture  of  undoubted 
acute  articular  rheumatism.  Osier's  ma.sterly  study  of  the  sul)ject  is  of 
most  value  in  considering  the  etiology  of  the  di.sease.  Among  the  other 
acute  infections  scarlet  fever  and  acute  pyemia  occasionally  antedate 
chorea. 

As  adult  life  is  approached  pregnancy  may  become  an  important  factor. 
Among  the  determining  factors  fright  and  mental  emotion  have  long 
been  considered  of  nuich  importance.  A  careful  study,  however,  of  a 
large  number  of  cases  leads  me  to  the  conclusion  that  they  have  little 
if  any  dir(>ct  influence  in  the  production  of  the  di.sease. 

Pathology. —  Many  minor  conditions  of  the  central  nervous  .system 
have  been  found.  To  none  of  th(\se,  however,  can  the  symptoms  with 
any  degree  of  certainty  be  ascribed.  Hyaline  degeneration  of  the  ves- 
sels, perivascular  leukocytic  infiltration,  capillary  hemorrhages,  cell 
degeneration,  and  throml)osis  of  the  cerebral  capillaries  have  been 
described  in  a  very  small  number  of  cases.  The  fact  that  all  of  these 
conditions  occur  not  infre(|uently  without  the  production  of  choreic 
movements  forces  us  to  consider  this  di.sease  ixs  a  functional  disorder 
of  the  motor  cortex.  This  is  also  borne  out  by  the  psychic  manifesta- 
tions. The  presence  of  emboli  of  the  cortical  vessels  and  of  embolism  of 
the  central  artery  of  the  retina  in  a  small  number  of  cases  may  be  con- 
sidered JUS  a  result  of  the  complicating  endocarditis  rather  than  as  a 
cause  of  the  flisease. 

Symptomatology. — Cases  of  chorea  divide  themselves  naturally  into 
three  groups  according  to  the  severity  of  the  affection:  (1)  mild  chorea, 
(2)  severe  chorea,  and  (3)  malignant  chorea,  or  chorea  insaniens. 


FUNCTIONAL   DISEASES  OF    THE  NERVOUS  SYSTEM         865 

Mild  Chorea. — After  a  week  or  so  of  depression  and  nervous  irrita- 
bility slight,  irregular,  purposeless  movements  are  noticed  in  one  of  the 
upper  extremities.  This  is  associated  with  a  pseudo  loss  of  power. 
There  is  a  tendency  in  nearly  all  cases  to  drop  articles,  such  as  dishes, 
spoons,  etc.,  even  before  the  parents  notice  the  irregular  movements. 
In  the  fully  developed  disease  this  inability  to  hold  articles  is  associated 
with  the  involuntary  movements.  At  the  beginning  of  a  choreic  jerk 
of  the  arm  the  hand  is  also  affected,  and  a  relaxation  of  the  grasp  occurs 
simultaneous  with  the  movement.  The  movements  extend  at  first  to  the 
lower  extremity  of  the  same  side  and  may  be  confined  to  one  side  of 
the  body  throughout  the  disease.  In  the  greater  number  of  cases  the 
disease  extends  to  the  opposite  side  and  to  the  face  until  all  the  voluntary 
muscles  are  affected.  The  movements  of  the  mild  form  of  the  disease 
cease  during  sleep.  The  tongue  may  be  affected  and  the  speech  become 
jerky  and  mumbling  in  character. 

In  a  small  proportion  of  cases,  independent  of  the  intensity  of  active 
motor  disturbance,  a  real  loss  of  power  occurs,  usually  hemiplegic  in 
distribution,  called  post-chorea  hemiplegia.  The  loss  of  power  never 
amounts  to  a  complete  paralysis,  but  may  be  sufficiently  intense  to  pro- 
duce difficulty  in  walking  and  an  inability  to  raise  the  arm  above  the 
level  of  the  shoulder.  In  a  case  recently  under  my  observation  the 
hemiplegia  was  so  marked  that  the  boy  was  compelled  to  drag  the  leg  in 
walking,  and  was  not  only  not  able  to  raise  the  arm,  but  was  unable  to 
hold  it  in  an  elevated  position  after  it  had  been  placed  there.  In  this  case 
the  choreic  movements  were  only  slightly  marked  and  confined  at  first  to 
the  palsied  side,  but  later  extended  to  the  rest  of  the  body.  The  weak- 
ness of  the  right  side  rapidly  disappeared  under  treatment. 

The  mentality  is  affected  even  in  mild  cases.  There  is  a  dull  expres- 
sion of  the  face  and  marked  irritability.  Outbreaks  of  temper  and 
marked  emotional  disturbances,  such  as  crying  spells,  are  frequent,  and 
in  a  small  number  of  cases,  night  terrors. 

Severe  Chorea. — The  symptoms  are  practically  the  same  as  those  of 
the  mild  form,  differing  only  in  intensity.  The  movements  become 
much  more  marked  and  constant,  the  respirations  become  jerky  and 
irregular,  the  heart  action  irregular,  and  the  child  speaks  only  with 
difficulty  and  with  an  accentuation  of  the  movements,  or  at  times  is 
unable  to  speak  at  all.  While  the  movements  in  this  form  are  only 
discontinued  during  sleep  they  may  in  some  cases  be  subdued,  and  the 
child  may  be  awakened  by  a  sudden  jerky  movement  of  an  arm  or  leg. 
Motor  weakness  is  in  this  form  the  rule,  but  whether  it  is  a  real  loss  of 
power  or  due  to  the  associated  movements  is  often  difficult  to  deter- 
mine. The  mental  symptoms  are  much  more  accentuated — the  child 
lacks  power  of  concentration,  is  very  irascible,  and  has  failure  of  memory. 
There  are  cases  on  record  of  distinct  mental  alienation,  melancholia, 
dementia,  etc.,  but  no  such  cases  have  come  under  my  own  observation. 
Fever  is  present  in  a  large  number  of  cases.  It  is  usually  very  slight, 
1°  to  2°,  but  at  times  may  be  as  high  as  101°  F.  A  decided  temper- 
g,ture  should  always  suggest  the  possibility  of  some  complication, 
55. 


SCG  DISEASES  OF   THE  NERVOUS  SYSTEM 

Malignant  Chorea  or  Chorea  Insanicns. — This  may  be  a  terminal 
condition  of  the  severe  form  or  may  develop  as  a  distinct  type  from  the 
beginnint>;.  It  occurs  more  frequently  as  we  approach  adult  life,  and 
there  is  usually  some  source  of  mental  worry  or  intense  anxiety  as  a 
complicating  factor  in  the  etiology.  The  motor  manifestations  become 
intense,  universal,  and  constant.  They  interfere  with  the  sleep  of  the 
pati(>nt,  and  rapid  exhaustion  occurs.  A  confused  delirium  or  a  wild 
maniacal  outbreak  ensues,  the  temperature  rising  as  high  as  104°  F.,  and 
a  fatal  termination  is  the  usual  result. 

Complications. — Conditions  usually  considered  rheumatic  in  char- 
acter are  the  most  frequent  complications.  The  most  important  of 
these  are  erythema  nodosum,  subcutaneous  rheumatic  nodules,  rheu- 
matic purpura,  and  cardiac  complications.      (See  p.  575.) 

Endocarditis. — Many  of  the  children  affected  are  in  such  a  poorly 
nourished  and  anemic  condition  that  functional  or  accidental  nuu-nuu-s 
would  naturally  be  expected.  Care  should  therefore  be  exercised  in 
differentiating  functional  murmurs,  which  occur  with  surprising  fre- 
quency, from  those  due  to  an  acute  active  endocarditis.  It  must  be 
remembered  that  organic  murmurs  sometimes  disappear.  A  soft  sys- 
tolic murmur  heard  along  the  base  of  the  heart  and  even  as  far  as  the 
left  sternal  margin,  with  a  normal  outline  of  cardiac  dulness,  in  a  poorly 
nourished  anemic  child,  may  be  considered  functional,  but  recjuires 
observation.  A  rough  or  harsh  murmur  either  with  or  without  asso- 
ciated enlargement  of  the  heart  and  displacement  of  the  apex  beat,  and 
also  heard  in  the  axilla,  indicates  an  active  valvular  endocarditis.  Osier 
found  in  72  of  140  patients  examined,  more  than  two  years  after  the 
attack,  evidence  of  organic  heart  disease. 

Pericarditis. — In  cases  with  distinct  evidences  of  articular  rheumatism 
pericarditis  is  an  occasional  complication. 

Herpes  zoster  occasionally  occurs,  and  may  be  attributed  to  the  use 
of  arsenic. 

Diagnosis. — If  the  irregular,  purpost^less  character  of  the  movements 
of  chorea  be  kept  in  mind  there  is  little  difficulty  in  making  the  diag- 
nosis. Friedreich's  ataxia  presents  slow,  irregular,  more  or  less  athe- 
toid  movements,  which  may  be  mistaken  for  chorea.  There  is,  how- 
ever, a  history  of  the  disease  affecting  other  members  of  the  family. 
Nystagmus,  a  scanning  speech,  and  loss  of  power  are  also  present. 
The  quick,  jerky  movements  of  chorea  are  altogether  different  from  the 
movements  of  Friedreich's  ataxia.  The  choreic  movements  of  hysteri- 
cal children  simulate  very  closely  at  times  those  of  true  chorea;  this  is 
particularly  so  where  the  children  have  an  opportunity  to  observe 
cases  of  true  chorea.  In  the  hysterical  type  the  individual  movements 
are  exaggerated,  usually  rhythmical  in  type,  and  frequently  disappear 
when  the  attention  of  the  child  is  distracted,  and  lessened  if  not  alto- 
gether absent  when  not  under  obser\ation.  There  are  usually  other 
associated  symptoms  of  hysteria:  convulsions,  anesthesias,  contraction 
of  the  visual  fields,  reversal  of  the  color  fields,  spasmodic  strabismus, 
etc.    The  diagnosis  can  usually  be  made  with  certainty  by  the  influence 


FUXCTIOXAL   DISEASES  OF   THE  XERVOUS  SYSTEM         867 

of  suggestion  and  hypnotism  as  they  completely  control  the  movements. 
It  is  to  be  remembered,  however,  in  this  connection  that  minor  hys- 
terical phenomena  are  frequently  present  in  true  chorea. 

The  motor  weakness  of  true  chorea  may  very  easily  be  mistaken  for 
an  organic  paralysis  due  to  hemorrhage  of  the  brain,  cerebral  embolism, 
poliomyelitis,  etc.  The  history  of  the  affection  develops  insidiously 
without  disturbances  of  the  reflexes  and  with  the  presence  of  the  choreic 
movements  which,  while  they  at  first  may  be  minor,  become  more  marked 
as  the  disease  progresses.  If  the  rule  of  diagnosis  of  nervous  affections 
of  childhood,  of  carefully  inspecting  the  naked  child  before  beginning 
the  routine  examination,  be  observed,  this  mistake  in  diagnosis  will  not 
occur. 

The  maniacal  form  of  malignant  chorea  may  with  some  difficulty  be 
mistaken  for  Bell's  mania,  hysterical  insanity,  etc.  Attention  to  the 
jerky,  irregular,  purposeless  character  of  the  movements  will  easily  lead 
to  a  correct  diagnosis. 

Treatment. — The  care  and  the  prevention  of  functional  disorders  of 
the  nervous  system  will  be  fully  treated  in  a  subsequent  chapter.  Chorea 
at  all  times,  even  in  the  milder  forms  of  the  affection,  is  sufficiently  serious 
to  demand  the  careful  attention  and  supervision  of  the  physician.  All 
cases  do  better,  the  course  of  the  disease  is  shortened,  and  the  danger 
of  complications  lessened,  by  confining  the  child  to  bed  during  the  period 
of  active  symptoms.  Anything  that  tends  to  produce  mental  excite- 
ment should  be  rigidly  excluded.  A  nurse  trained  to  handle  nervous 
conditions  is  a  very  helpful  adjunct  to  the  treatment.  The  diet  should 
be  simple  and  nutritious,  with  tea  and  coffee  excluded.  In  the  severe 
cases  isolation  is  necessary.  Care  should  always  be  used  in  permitting 
visitors;  strangers  should  be  excluded  from  the  sick-room,  and  even 
members  of  the  family  when  their  visits  or  presence  produce  undue 
excitement.     School  duties  and  intellectual  efforts  should  be  avoided. 

Gentle  massage,  with  warm  bathing  and  a  warm  or  cold  wet  pack 
often  have  a  quieting  influence  when  properly  administered.  It  is 
quite  necessary  in  the  poorly  nourished,  where  overfeeding  is  necessary, 
to  keep  the  muscles  in  good  condition  by  routine  massage,  followed 
during  convalescence  by  passive  and  resisted  movements.  These, 
however,  should  be  carefully  watched  and,  if  any  tendency  to  accentua- 
tion in  the  motor  phenomena  is  manifested  they  should  be  decreased 
or  stopped  altogether.  Electricity  is  sometimes  of  value  both  as  a  body 
stimulant  and  in  keeping  the  muscles  in  good  condition,  but  often  pro- 
duces too  much  excitement  to  be  used.  Galvanism  should  be  appHed 
in  preference  to  faradism. 

The  medicinal  treatment  is  confined  to  the  use  of  aherative  tonics 
and  nerve  sedatives.  Of  the  former  arsenic  in  the  form  of  Fowler's 
solution  is  of  distinct  value.  It  should  be  given  in  small  doses  0.12  to  0.3 
c.c.  (two  to  five  drops)  and  increased  by  one  drop  a  day  until  fifteen  drops 
are  reached.  In  older  children  it  may  be  increased  to  1.2  c.c.  (twenty 
drops)  three  times  a  day.  It  is,  however,  inadvisable  to  give  large  doses 
in  cases  not  under  the  direct  observation  of  the  physician.    Pain  or  other 


868  DISEASES  OF   THE  NERVOUS  SYSTEM 

disturbance  of  the  .stomach  with  puffiness  about  the  eyes  should  be  the 
signal  to  stop  the  use  of  the  drug.  It  may,  however,  be  continued  later. 
The  long-continued  use  of  arsenic  may  lead  to  arsenical  neuritis. 
Care  should  therefore  be  used  in  prescribing  this  drug  in  dispensary 
cases. 

Donovan's  solution  of  iodide  of  arsenic  and  mercury,  in  doses  of  0.12 
to  0.3  c.c.  (two  to  five  drops)  three  times  daily.  Strychnine,  cimicifuga, 
and  belladonna  may  be  of  use.  In  cases  where  there  is  marked  irrita- 
bility, bromide  of  soda  in  combination  with  small  doses  of  strychnine 
has  a  very  sedative  effect.  The  bromides  and  trional  in  doses  of 
from  0.325' to  0.65  gm.  (5  to  10  gr.)  are  of  value  in  disturbed  or  restless 
sleep. 

Inasmuch  as  recurrences  of  this  affection  are  very  common  (as  often 
as  six  to  eight  attacks  in  successive  years  being  recorded)  great  care 
should  be  used  in  the  hygienic  surroundings  of  such  children,  and  they 
should  be  removed  from  the  overwork  and  excitement  of  the  spring  exam- 
inations, particularly  at  the  public  schools,  at  which  time  relapses  fre- 
Cjuently  occur. 

Chorea  Major. — The  Chorea  Major  (Epidemic  Hysterical  Chorea),  the 
dancing  epidemics  of  the  Middle  Ages,  to  which  the  terms  Saint  Vitus' 
dance,  Saint  Anthony's  dance,  etc.,  were  originally  applied,  finds  its  pro- 
totype of  the  present  day  in  epidemics  of  hysterical  outbreaks  among 
negroes  at  religious  revivals.  There  is  a  condition  occasionally  met- 
w^ith  in  institutions  for  the  care  and  education  of  children  resembling  true 
chorea  and  affecting  large  numbers  of  children.  In  the  epidemic  reported 
by  Weir  Mitchell  at  the  Church  Home  for  Children  near  Philadelphia 
there  were,  besides  rhythmic  clioreic  movements,  hysterical  convulsions, 
illusions,  and  hallucinations  affecting  a  large  number  of  children.  The 
clinical  picture  was  the  same  in  all  the  cases,  with  slight  modifications, 
and  was  suggested  to  the  children  affected  by  the  attack  of  the  first 
child.  E])ideniics  of  this  affection  are  best  treated  by  isolation  of  the 
individual  cases,  rest  in  bed,  massage,  overfeeding,  and  suggestion. 

Diagnosis. — The  absence  of  fever,  the  normal  condition  of  the  reflexes, 
and  the  evident  hysterical  character  of  the  affection  will  differentiate  it 
from  epideunc  cerebros])inal  meningitis. 

Habit  Chorea. — Habit  Sj)asm  or  Convulsive  Tic.  This  condition  is 
very  fre(juently  met  with  in  children  from  six  to  fourteen  years  of  age, 
although  it  may  occur  at  any  time  of  childhood  or  adult  life.  In  chil- 
dren of  neurotic  temperament,  or  those  with  an  apparently  normal 
nervous  mechanism,  l)ut  with  defective  home  or  school  training,  and  in 
"spoiled  children"  who  have  never  been  subjected  to  proper  discipline 
or  training,  habit  spasms  are  of  fre(juent  occurrence.  The  movements 
differ  from  those  of  Sydenham's  chorea  by  their  evident  purposive 
character  and  their  localization  to  a  single  muscle  or  a  group  of 
muscles. 

Symptomatology. — The  muscles  of  the  face  are  most  frequently 
affected.  A  sudden,  quick  blinking  of  the  eyes,  which  may  be  repeated 
very  frequently  at  short  intervals,  or  occur  only  a  few  times  during  the 


FUNCTIONAL  DISEASES  OF   THE  NERVOUS  SYSTEM        869 

day,  is  the  form  most  frequently  met  with.  The  eyebrows  in  other 
cases  are  suddenly  elevated ;  the  face  may  be  drawn  to  one  side,  or  the 
facial  muscles  of  both  sides  may  be  affected,  producing  a  sudden  involun- 
tary grin.  The  tongue  may  be  affected,  and  a  sudden  movement  of 
the  tongue  as  if  moistening  the  lower  lip  may  be  so  frequently  repeated 
as  to  produce  an  inflamed  condition  of  the  skin  of  this  area.  In  one 
child  who  had  been  able  voluntarily  to  produce  a  movement  of  the  ears, 
a  sudden  jerky  movement  of  both  ears  developed  independent  of  the 
volition  of  the  patient.  Spasm  of  the  muscles  of  the  neck  result  in  a 
jerking  of  the  head  to  one  side;  shrugging  of  one  or  both  shoulders  is 
not  infrequent. 

There  are  usually  no  other  symptoms  apart  from  the  motor  phenomena. 
Hysterical  outbreaks  are  occasionally  met  with  in  the  type  of  children 
subject  to  this  affection. 

Diagnosis. — In  rare  cases  several  groups  of  muscles  may  be  affected 
at  the  same  time,  but  they  can  be  easily  differentiated  from  Sydenham's 
chorea  by  the  purposive  character  of  the  movements. 

There  is  a  condition  of  the  muscles  of  the  face,  most  frequently  localized 
to  the  orbicularis  palpebrarum  and  due  to  the  toxic  influence  of  tea 
and  coffee  on  the  nervous  mechanism,  which  should  be  distinctly  differ- 
entiated from  habit  spasm.  The  manifestations  are  lightning-like  con- 
tractions of  the  individual  fibrillse,  affecting  all  of  these  fibrillse  in  rapid 
succession,  producing  at  the  most  a  slight  quivering  motion  of  the  lids, 
but  never  leading  to  the  distinct  blinking  of  habit  chorea.  This  is  as 
frequently  met  with  in  adult  life  as  in  children,  and  rapidly  yields  to 
treatment  when  tea  and  coffee  are  excluded  from  the  diet.  In  some  of 
the  cases  eye  strain  is  a  factor. 

Habit  spasm  should  also  be  differentiated  from  what  has  been 
described  as  impulsive  tic  (Gilles  de  la  Tourette's  disease).  Some  of  the 
forms  of  this  condition  appear  to  me  to  be  a  more  serious  and  wide- 
spread affection  of  the  toxic  condition,  above  described,  affecting  the 
orbicularis  palpebrarum,  and  due  to  some  intoxication  of  the  system. 
It  is  not  infrequently  fatal.  It  begins,  as  a  rule,  in  very  early  life, 
although  it  may  occur  as  late  as  early  adult  life.  The  muscular  move- 
ments may  affect  all  the  voluntary  muscles,  are  lightning-like  in  char- 
acter, with  marked  fibrillary  movements.  Another  group  of  cases 
described  under  this  condition  presents  the  same  quick  action  of  the 
muscles,  with  mental  disturbance  and  the  use  of  foul  language.  The 
explosive  quick  character  of  the  movements,  the  mental  disturbance, 
and  the  coprolalia  should  differentiate  it  from  either  Sydenham's  or 
simple  habit  chorea. 

Treatment. — In  both  habit  spasm  and  impulsive  tic  an  underlying 
cause  should  be  carefully  searched  for  and  removed.  In  the  habit  spasm 
about  the  eyes  errors  of  refraction  and  loss  of  muscle  balance  should  be 
first  corrected.  The  mucous  membrane  of  the  nose  and  the  condition 
of  the  turbinated  bodies  should  be  examined  to  determine  any  cause 
for  irritation.  The  ears  and  teeth  should  in  the  same  way  receive 
attention  in  all  cases  where  the  symptoms  are  referable  to  any  part 


870  DISEASES  OF    THE  XERVOUS  SYSTEM 

of  the  face.  Irritative  reflex  di.sturl)aiices  in  the  genitourinary  tract, 
such  as  ])hinio.sis,  etc.,  should  l)e  reheved.  One  case  of  complex 
shrugging  movements  about  the  shoulders  and  twisting  movements  of 
the  trunk  resisted  treatment  until  a  rough  woollen  sweater  which  the 
boy  wore  next  to  the  skin  had  been  replaced  l)y  proper  underclothing. 
The  spasm  then  rapidly  disappeared. 

The  general  nutrition  of  the  body  should  be  brought  to  a  normal 
standard  and  a  proper  discipline  infused  in  a  routine  way  into  the 
child's  life.  AVhile  punitive  disciplinary  measures  sometimes  succeed 
in  early  imitative  cases  they  frequently  do  harm.  The  child  should  be 
sent  to  bed  at  a  definite  time  early  in  the  evening  and  compelled  to 
remain  in  bed  an  hour  after  the  usual  time  of  rising,  both  as  a  disciplinary 
measure  and  to  secure  an  added  amount  of  rest  for  the  weakened 
nervous  system.  A  period  of  rest  in  the  middle  of  the  day  is  also  advis- 
able. A  cold  sponge  bath  or  needle  bath  is  valuable  as  a  tonic  stimulant 
if  the  child  reacts  well.  A  simple  diet  without  tea  and  coffee  and  with 
little  meat,  l)ut  with  plenty  of  milk,  eggs,  and  vegetables  is  indicated. 
Alterative  tonics,  such  as  Fowler's  solution,  quinine,  and  strychnine,  are 
sometimes  of  value;  more  frequently  better  results  are  secured  by  the 
use  of  bromides  and  other  nerve  sedatives.  The  child  should  be  encour- 
aged to  inliibit  the  movements  as  far  as  possible. 

Electric  Chorea. — This  is  a  rare  disease,  first  described  by  Dubini, 
and  is  manifested  as  intensely  rapid  rhythmic  movements  in  the  extrem- 
ities, rarely  in  the  head  and  face.  The  movements  may  be  very  violent, 
and  have  the  appearance  as  if  produced  by  an  electric  shock.  In  the 
severe  form  described  by  Dubini  as  occurring  in  Italy,  paralytic  symp- 
toms supervene,  and  may  be  associated  with  epileptiform  convulsions. 
Pain  in  the  head  and  neck  may  be  present  early,  and  toward  the  end  of 
the  attack  atrophy  and  wasting  of  the  muscles  may  occur.  Fever  may 
be  present.  The  cases  terminates  in  a  few  weeks  or  a  month  from 
heart  failure  or  coma.  A  form  of  electric  chorea,  probably  due  to 
hysteria,  has  been  described  by  Bergeron.  Henoch  has  also  described 
a  form  of  electric  chorea  differing  from  both  the  above,  and  mani- 
fested by  spasmodic  attacks  of  lightning-like  contractions  confined 
to  the  muscles  about  the  shoulder-blade,  it  is  probably  a  form  of 
myoclonus. 

Treatment. — This  should  be  directed  to  the  removal  of  any  underlying 
intoxication.  Free  purgation,  chloral  and  the  bromides  have  been  used, 
but  to  little  effect. 

Chronic  Progressive  Chorea. — While  this  disease,  described  as 
Huntingdon's  chorea,  is  typically  a  disease  of  adult  life,  a  peculiar 
condition  resembling  the  adult  form  developed  in  a  child,  the  third 
son  of  a  member  of  a  family,  all  of  whom  have  either  died  of  or  at 
present  have  Huntingdon's  chorea.  About  the  second  year  of  life 
choreiform  movements  resembling  the  movements  of  Sydenham's  type 
began  in  one  of  the  lower  extremities  and  spread  to  the  rest  of  the  body. 
The  movements  continued  for  over  a  period  of  tw^o  years  and  death 
occurred  from  scarlet  fever.     Remak  and  Oppenheim  have  described 


FUNCTIONAL   DISEASES  OF   THE   NERVOUS  SYSTEM        871 

a  similar  condition  affecting  several  children  of  a  woman  suffering  with 
permanent  hemichorea. 

Diagnosis. — This  disease  can  be  differentiated  from  Sydenham's 
chorea,  which  it  closely  resembles  in  the  clinical  picture,  by  the  presence 
of  the  adult  form  of  chorea  in  one  of  the  parents  and  the  chronic  nature 
of  the  affection. 

Treatment. — No  method  of  treatment  has  produced  appreciable  re- 
sults in  this  disease.  Hypnotic  suggestion  may  control  the  movements 
temporarily.     The  mental  deterioration  demands  asylum  treatment. 

Organic  Choreas.  Post-hemiplegic  Chorea. — After  some  of  the  cerebral 
palsies  of  childhood,  which  will  be  later  described,  a  series  of  movements 
develops  in  the  palsied  arm,  to  which  the  name  of  chorea  has  been 
erroneously  given.  These  movements  are:  (a)  gross  rhythmic  tremors; 
(b)  athetoid  movements  (slow,  snake-like  movements  of  the  extremity), 
which  may  be  constant  during  the  waking  hours  or  brought  on  by 
attempts  at  volitional  movement  and  could  not  be  mistaken  for  the 
quick,  jerky  movements  of  Sydenham's  type  or  the  purposive  move- 
ments of  habit  chorea. 

Minor  athetoid  movements  may  be  present,  with  practically  no  loss 
of  power  in  organic  lesions  sufficiently  near  the  motor  fibres  of  the 
brain  to  produce  irritation  without  destruction. 

Athetoid  movements  at  times  become  so  annoying  that  amputation 
of  the  offending  part  has  been  done,  but  the  results  are  not  in  propor- 
tion to  the  gravity  of  the  operation.  Recently  transplantation  of  the 
tendons  has  been  suggested  by  Spiller  with  much  benefit. 

Prehemiplegic  Chorea. — This  is  very  rarely  if  ever  met  with  in  children, 
but  is  of  not  infrequent  occurrence  in  adult  life  immediately  preceding 
an  apoplectic  attack.  It  is  due  to  vascular  nutritional  changes  and 
follows  one  of  the  above  forms  of  movement. 


THE  CONVULSIVE  DISORDERS  OF  CHILDHOOD. 

REFLEX  CONVULSIONS. 

The  nervous  system  of  the  infant  is  so  sensitive  to  the  influence  of 
toxins  and  reflex  irritation  that  a  convulsion  is  not  an  infrequent  occur- 
rence in  the  life  history  of  a  normal  child.  It  should,  however,  always 
be  borne  in  mind  that  convulsions  in  infancy  or  childhood  which  may 
be  ascribed  to  slight  causes,  such  as  teething,  minor  infections,  etc., 
denote  an  unstable  condition  of  the  motor  nervous  system,  which  may 
develop  a  convulsive  habit  with  greater  ease  and  with  less  cause  than  in 
a  normal  nervous  system.  The  onset  of  the  infectious  fevers,  especially 
those  associated  with  high  fever,  are  very  prone  to  be  ushered  in  with 
convulsions.  This  is  probably  due  more  to  intoxication  than  to  the 
febrile  disturbance.  Peripheral  irritation  of  the  gastroenteric  tract, 
intestinal  fermentation,  intestinal  parasites,  genitourinary  irritation 
(phimosis),  nasopharyngeal  irritation  (adenoids),  delayed  dentition,  and 


872  DISEASES  OF   THE  XERVOUS  SYSTEM 

rickets  arc  frequent  causes  of  convulsive  disturbances,  rickets  being 
the  most  common  underlying  vice  of  constitution  which  predisposes  to 
this  instability.  Cerebral  hemorrhage  and  other  organic  lesions  of 
the  brain  are  associated  with  convulsions.  Extreme  passive  congestion 
such  as  that  caused  by  the  paroxysms  of  whooping-cough  may  also 
cause  convulsions  by  minute  or  gross  extravasations  of  blood  in  the 
brain  cortex. 

Symptomatology. — The  convulsions  vary  so  in  the  clinical  picture  that 
it  is  rare  for  two  to  be  exactly  alike.  They  usually  come  on  suddenly 
without  previous  warning,  and  with  or  without  an  incidental  cry;  the 
bodv  is  suddenly  thrown  in  a  condition  of  tetanic  spasm,  the  head  is 
retracted,  the  eyes  turn  up,  the  pupils  are  dilated,  antl  do  not  react 
to  light.  Clonic  convulsions  may  follow  or  they  may  be  entirely  absent. 
The  mother  usually  gives  a  history  of  "  inward  spasms,"  i.e.,  a  purely 
tonic  spasm  without  the  clonic  convulsions.  In  some  cases,  restless- 
ness and  twitching  of  the  muscles  of  the  arms,  grinding  of  the  teeth  in 
older  children,  may  precede  the  convulsive  stage.  The  spasms  usually 
begin  in  the  upper  extremities.  The  l)ody  is  held  rigid,  the  eyes  fixed,  the 
head  retracted  and  breathing  is  suspended  for  a  short  time,  as  a  result 
of  which  the  face  becomes  congested.  Fo:- a  minute  or  two,  slight  or 
extensive  jerkings  of  the  extremities  may  follow.  After  they  cease,  the 
child  falls  into  a  natural  sleep,  or  more  frequently  into  a  state  of  stupor, 
or  in  fatal  cases  into  a  deep  coma.  It  is  \mcommon,  except  in  pure  re- 
flex convulsions  due  to  overloading  of  the  stomach,  or  those  ushering 
in  an  acute  infection,  for  the  convulsions  to  be  single.  It  is  a  rule  to 
have  repeated  convulsions  which  may  be  separated  from  one  another  by 
a  distinct  interval,  or  the  convulsions  may  follow  each  other  in  rapid 
succession.  In  such  cases,  the  child  may  never  recover  from  the  coma- 
tose condition.  It  is  exceptional  to  have  a  fatal  outcome  of  the  single 
Isolated  convulsions.  After  the  convulsioas  have  disappeared,  the  child 
may  present  nothing  abnormal  in  an  examination  of  the  nervous  sys- 
tem. It  is  not  infrequent  however,  to  find  a  weak  or  paretic  condition 
of  one  side  of  the  body,  wdiich  may  rapidly  disappear.  Complete 
hemiplegia,  persistent  in  type,  which  later  becomes  spastic.  Is  not  in- 
frequently seen. 

The  persistence  of  the  convulsive  habit  is  a  matter  for  serious  con- 
sideration. In  unstable  children,  every  effort  should  be  made  to  pre- 
vent recurring  attacks  and  to  minimize  tlie  danger  to  the  nervous 
system  by  lessening  the  intensity  of  the  individual  attacks.  In  the 
analysis  of  1450  cases  of  epilepsy,  Gowers  found  that  ISO  began  during 
the  first  three  years  of  life.  Osier  gives  a  much  higher  percentage;  of 
460  cases  of  epilepsy  in  children,  187  began  during  the  first  three 
years;  74  of  these  began  during  the  first  year.  It  does  not  follow, 
however,  that  convulsions  during  childhood  necessarily  imply  epileptic 
attacks  during  later  life.  Great  care,  however,  should  be  taken  of  such 
children  to  relieve  the  developmental  period  of  life  from  any  unneces- 
sary strain  on  the  nervous  system,  and  to  guard  the  child  from  reflex 
irritability. 


THE  CONVULSIVE  DISORDERS  OF  CHILDHOOD  873 

Prognosis. — In  simple  reflex  convulsions  the  prognosis,  so  far  as  life 
is  concerned,  may  be  considered  to  be  good;  the  large  mortality  in 
children,  as  put  down  in  the  health  reports  as  due  to  convulsions, 
embraces  such  a  large  variety  of  conditions,  including  the  organic  palsies 
of  childhood,  meningeal  hemorrhage,  uremia,  etc.,  that  they  lead  to  a 
false  impression  as  to  the  mortality  of  this  afl'ection.  There  is,  however, 
not  only  danger  of  d^ath  from  asphyxia,  but  also  a  possibility  of  hemor- 
rhagic extravasation,  which  may  lead  to  paralysis.  Repeated  con- 
vulsions if  not  controlled  may  finally  develop  into  major  epilepsy. 

Treatment. — The  same  precautions  to  safeguard  the  general  health  of 
the  child  and  to  establish  a  proper  stability  of  the  nervous  system,  as 
suggested  for  epilepsy,  should  be  carried  out.  Reflex  causes  should 
be  removed  as  far  as  possible.  For  the  treatment  of  the  individual 
convulsion,  the  hot  bath  at  100°  to  105°  F.  in  slight  cases  may  be 
of  some  benefit;  in  the  severe  convulsions  it  is  of  little  value  and 
takes  up  time  that  should  be  devoted  to  other  measures.  Inhalations  of 
chloroform  or  nitrite  of  amyl,  or  equal  parts  of  both,  should  be  continued 
until  the  convulsions  have  disappeared.  Enemata  to  empty  the  large 
intestine  will  be  helpful  in  a  great  many  cases.  Small  doses  of  opium 
in  combination  with  the  bromides  will  usually  prevent  the  return  of 
convulsions.  After  a  day  or  two  the  bromides  or  chloral  should  be 
reduced  to  smaller  doses  and  kept  up  for  at  least  a  week.  In  acute 
febrile  cases  means  should  be  used  to  reduce  the  temperature  in  order 
to  guard  against  subsequent  attacks.  Where  gastric  irritation  is  present 
calomel  should  be  used  to  evacuate  the  bowels.  Convulsions  with 
marked  laryngeal  symptoms  (laryngismus  stridulus)  should  be  treated 
on  the  same  principles;  the  child,  however,  should  be  held  in  an  upright 
position  and,  if  breathing  is  too  markedly  interfered  with,  traction  of  the 
tongue  or  cold  douches  to  the  chest  should  be  employed.  Rickets,  which 
is  present,  is  often  a  predisposing  factor,  and  should,  of  course,  receive 
careful  dietetic  and  hygienic  consideration. 


EPILEPSY. 

Epileptic  attacks  in  childhood  may  be  divided  for  purpose  of  descrip- 
tion into  (1)  Grand  Mai,  (2)  Petit  Mai. 

Etiology. — At  least  one-fourth  of  all  cases  of  this  disease  begin  before 
the  tenth  year  of  age,  and  the  great  majority  of  the  remainder  (at  least 
three-fourths)  before  the  twentieth  year.  The  few  remaining  cases 
may  occur  at  any  time  of  life,  but  a  careful  investigation  of  the  early 
history  will  usually  reveal  some  evidence  of  epileptic  manifestations 
in  childhood.  Thus,  a  young  woman  of  twenty-six  years,  suffering  from 
epileptic  convulsions  for  the  past  two  years,  had  attacks  of  petit  mal 
in  childhood,  which  were  not  considered  of  sufficient  importance  at  the 
time  to  merit  medical  attention.  Females  are  more  likely  to  be  affected 
than  males.  This  is  especially  true  about  the  time  of  puberty  and 
under  the  influence  of  the  development  of  the  menstrual  period. 


874  DISEASES  OF   THE  XERVOUS  SYSTEM 

Heredity  is  an  especially  important  etiological  factor.  The  heredity 
of  distinct  epilepsy,  although  present  according  to  some  observers  in 
40  per  cent,  of  the  cases,  is  of  not  such  frecpicnt  occurrence  as  hysteria, 
insanity,  syphilis,  and,  possibly,  alcoholisTU  in  the  parents.  Constant 
reflex  irritation  is  often  a  determining  factor  in  the  production  of  epileptic 
attacks.  In  an  individual  with  an  unstable  nervous  system,  constant 
reflex  irritation  along  the  gastroenteric  or  the  genitourinary  tract,  if 
not  relieved  before  the  convulsive  habit  is  thoroughly  developed,  may 
lead  to  the  formation  of  a  true  epilepsy. 

S3nnptomatology.  1.  Petit  Mai. — A  child  with  petit  mal  may  show 
nothing  more  than  a  sudden  loss  of  consciousness,  lasting  from  a  few 
seconds  to  several  minutes.  The  child  suddenly  stops  in  its  play  or  in 
the  middle  of  a  conversation,  becomes  pale,  or,  perhaps,  flushed,  has 
a  dazed  expression,  and  either  resumes  the  conversation  without  any 
knowledge  of  its  interruption,  or  may  be  confused,  slightly  incoherent, 
and  perform  some  simple  or  complex  automatic  act.  In  those  cases  in 
which  the  attack  is  of  some  duration  the  child,  if  he  happen  to  be  at 
the  time  walking,  may  continue  and  suddenly  find  himself  in  some 
strange  location.  I  have  known  cases  of  sudden  unconsciousness  in 
epilepsy  to  last  as  long  as  an  hour,  during  which  time  a  variety  of 
complex  and  apparently  conscious  anfl  rational  acts  are  committed  of 
which  there  is  absolutely  no  recollection,  or  only  a  dim  recollection 
of  those  at  the  beginnmg  of  the  attack.  To  this  form  the  term  psychic 
epilepsy  has  been  applied.  Petit  mal,  or  psychic  epilepsy,  may  exist 
alone  or  in  combination  with — ■ 

2.  Grand  Mal. — The  grand  mal,  or  the  epileptic  fit,  as  occurring  in 
childhood,  may  present  any  one  or  all  of  the  following  manifestations: 

(a)  Aura  or  signal  symptom.  Immediately  preceding  the  attack  a 
warning  of  its  approach  is  frequently  given,  which  may  be  of  only 
momentary  duration  or  sufficiently  long  to  enable  the  patient  to  protect 
himself  from  injury.  Most  frequently  this  sensation  is  a  feeling  of 
discomfort  or  an  indefinable  sensation  beginning  in  the  stomach  or  some 
of  the  other  viscera,  and  either  remaining  localized  there  or  ascending 
to  the  head,  when  consciousness  is  lost.  In  a  boy  of  six  years  precordial 
distress  and  palpitation  ushered  in  the  attack.  A  sensation  of  a  breeze 
may  be  present  in  the  extremity.  Flashes  of  light  before  the  eyes,  or 
colored  balls  may  be  seen;  a  peculiar  soimd  or  word  or  sentence  may  be 
heard;  a  peculiar  taste  or  odor  or,  in  some  cases,  even  an  idea,  a  land- 
scape, a  ^•ision  of  creeping  bugs,  or  of  snakes  may  be  present  before  the 
attack.  Slight  motor  disturbances  may  be  present  before  consciousness 
is  lost.  A  few  seconds  after  the  beginnincr  of  the  aura  the  child  falls 
suddenly  and  heavily  to  the  floor  in  a — 

(b)  Tonic  spasm.  Consciousness  is  now  lost;  the  head  is  retracted 
and  may  be  turned  to  one  side.  The  extremities  and  the  muscles  of 
the  trunk  are  in  rigid  spasm,  respiration  ceases,  the  face  becomes 
cyanosed,  and  in  a  few  seconds  the — 

(c)  Clonic  spasm  begins.  The  child  begins  to  jerk  the  extremities 
rh}ihmically,  the  arms  being  slightly    flexed    and    extended.     The  ex- 


THE   CONVULSIVE  DISORDERS  OF   CHILDHOOD  875 

tended  legs  are  likewise  affected  and  beat  a  tattoo  with  the  heels  on  the 
floor;  the  face  is  involved  in  the  rhythmical  contraction,  the  respirations 
are  stertorous,  the  eyes  are  turned  upward  and  may  be  the  seat  of 
jerky  movements,  the  tongue  may  be  bitten  and  bloody,  and  frothy 
saliva  may  stain  the  face  and  clothing.  The  bladder  is  very  fre- 
quently and  the  rectum  occasionally  evacuated  during  the  attack. 
This  clonic  stage  may  last  from  a  half  to  five  minutes  and  then  pass 
over  into  the — 

(d)  Comatose  stage.  The  jerkings  gradually  cease,  breathing  becomes 
less  stertorous,  the  muscles  become  relaxed,  consciousness  is  still  lost, 
and  the  eyes  remain  either  wide  open  or  half  closed.  This  condition 
gradually  goes  over  into  natural  sleep,  from  which  the  patient  awakens 
in  a  semidazed  condition  with  headache  and  soreness  of  the  muscles  and 
tongue.  In  some  cases  automatic  actions  occur,  such  as  taking  off  the 
clothes,  running  movements,  etc.  Maniacal  outbreaks  sometimes  follow 
the  attack  and  a  gradual  loss  of  mental  power  is  the  rule  where  the 
attacks  occur  at  frequent  intervals.  A  monoplegic  or  hemiplegic  par- 
alysis, temporary  in  character,  very  rarely  follows  the  fit.  The  child  is 
always  unconscious  during  an  attack  of  true  epilepsy. 

Diagnosis. — Hysteria,  uremia,  and  simple  reflex  convulsions  may  be 
mistaken  for  epilepsy.  The  epileptic  convulsion  is  distinguished  from 
the  hysterical  convulsion  by  the  loss  of  .consciousness,  the  sequence  of 
the  different  stages  above  described,  the  rhythmic  movements  affecting 
the  flexors  and  the  extensors,  the  relaxation  of  the  vesical  and  rectal 
sphincters,  and  the  biting  of  the  tongue.  Uremic  convulsions  may 
closely  simulate  the  epileptic  convulsion,  but  are  easily  separated  from  it 
by  the  examination  of  the  urine  and  the  associated  vascular  symptoms. 
The  reflex  convulsions  of  childhood  do  not  differ  from  real  epilepsy  in 
infancy. 

Prognosis. — As  a  general  rule,  the  earlier  in  life  the  convulsive  epileptic 
habit  becomes  established  the  more  incurable  it  is.  In  rare  cases  the 
convulsions  may  cease  under  appropriate  treatment  as  adult  life  is 
approached.  Where,  however,  the  convulsions  occur  at  frequent  inter- 
vals, not  only  is  there  little  hope  of  control,  but  distinct  mental  deterio- 
ration may  be  expected. 

Treatment. — A  careful  examination  for  visceral  disturbances  and  a 
correction  as  far  as  possible  is  a  very  necessary  preliminary  to  the  treat- 
ment of  this  disease.  Reflex  disturbances  in  the  nasopharyngeal  gas- 
troenteric and  genitourinary  tracts  should  be  carefully  sought  for  and  re- 
moved. Particular  attention  should  be  paid  throughout  the  treatment  to 
keeping  the  stomach  and  bowels  in  good  condition.  The  bowels  should 
be  moved  every  day;  constipation  and  overloading  the  stomach  are  the 
most  frequent  determining  factors  of  the  individual  attacks.  Intestinal 
toxemia  due  to  the  improper  ingestion  of  meats  is  such  a  deleterious 
factor  that  it  has  been  my  rule  to  insist  on  a  vegetable  and  milk  diet. 
Tea,  coffee  and  tobacco  should  be  absolutely  prohibited.  A  life  as 
free  from  excitement  as  possible,  preferably  in  the  country,  should  be 
enjoined.     Regularity  in  habits  of  eating,  sleeping,  and  exercise  is 


870  DISEASES  OF    THE   XERVDUS   SYSTEM 

necessary  in  order  to  restore  as  far  as  ])()ssil)le  a  proper  balance  and 
reirularity  of  function  of  the  nerve  tissues.  The  exercise  should  be 
cart>fully  re»^ulated  to  secure  a  proper  condition  of  the  muscles,  with  the 
least  excitement  and  the  least  fatigue.  A  ])eriod  of  sleep  in  the  middle 
of  the  day  lessens  the  mental  and  physical  fatigue  and  prevents  the 
early  night-sleep  from  being  too  intense.  A  large  number  of  cases  have 
their  fits  at  night,  and  usually  when  sleep  is  deepest. 

Many  drugs  are  recommended  for  the  cure  or  control  of  this  afft^'tion. 
The  bromides  are  by  far  the  best  medicinal  agents  at  our  command. 
Sufficient  bromide  should  be  given  to  control  the  attacks.  In  nocturnal 
epilepsy  as  high  as  3.90  gm.  (1  dr.)  of  sodium  bromide  may  be  given 
in  a  single  dose  before  the  child  retires.  A  nmch  smaller  (juantity  may 
be  sufficient,  but  this  is  a  matter  of  experiment  in  each  individual 
case. 

When  the  attacks  occur  during  the  day  from  0.324  to  1.3  gm.  (5  to 
20  gr.)  doses  may  be  given  after  each  meal.  When  the  attacks  occur  at 
periodic  intervals  (approximately  every  month  in  a  case  at  present  under 
my  care)  the  dose  may  l)e  doubled  a  few  days  pr(>vious  to  the  time  of 
the  expected  attack.  Where  control  of  the  convulsions  is  secured,  both 
the  hygienic  and  drug  treatment  should  be  continued  for  at  least  two 
years  after  the  last  attack.  Arsenic  in  the  form  of  Fowler's  solution 
assists  in  controlling  skin  manifestations  of  the  bromides.  Acetanilid, 
phenacetin,  chloretone,  may  be  combined  in  0.324  gm.  (5  gr.)  doses  with 
the  bromides,  or  given  separately  when  it  is  considered  advisable  to 
intermit  the  bromide  treatment,  on  account  of  gastric  disturbance  or 
mental  symptoms.  Care,  however,  should  be  used  to  prevent  cardiac 
depression  from  the  use  of  these  drugs. 

Solanum  cariolensis  in  1.25  to  3.75  c.c.  (gtt.  xx  to  foj)  of  the  fluid 
extract  may  also  be  used  as  a  substitute  for  the  bromides.  The  treatment 
of  the  individual  attack  consists  merely  in  prevention  of  injury  to  the 
tongue  or  the  person.  A  towel  inserted  between  the  teeth  and  a  pillow 
placed  beneath  the  head  meet  these  re(juirements.  Wh(Mi  one  convulsion 
follows  the  other  in  rapid  succession  (epileptic  status)  free  purgation 
should  be  obtained.  Chloral  and  bromide  by  rectum  are  most  satisfactory 
as  sedatives.  The  patient  may  be  bled,  but  very  young  children  do  not 
bear  the  loss  of  much  blood. 


HYSTERIA. 

Hysteria  is  a  comparatively  rare  disease  of  childhood.  It  is  the  typical 
functional  nervous  disease  for  which  there  is  no  known  pathology. 

Etiology. — It  is  much  more  frequent  in  the  female  sex,  especially  as 
adult  life  is  approached.  It  is  also  of  nuich  more  frequent  occurrence 
in  the  Latin  races.  A  neurotic  heredity  is  very  frequently  present.  The 
"germ"  of  hysteria  may  be  said  to  l)e  present  in  every  female  child;  and 
in  those  of  a  nervous  temperament,  the  worry  of  forced  schooling, 
overwork,  fright,  or  any  intense  emotional  disturbance  may  determine 


THE  COXVULSIVE  DISORDERS  OF   CHILDHOOD  877 

an  outbreak.     Masturbation  is  an  important  etiological  factor  in  both 
sexes  and  must  not  be  overlooked  in  girls. 

Symptomatology. — The  clinical  picture  of  hysteria  varies  so  widely 
that  it  would  be  impossible  in  a  short  space  to  give  an  adequate  account 
of  its  protean  manifestations.  ^Ye  may  divide  the  symptoms  into  several 
groups,  but  it  must  be  remembered  that  every  possible  combination 
of  these  may  occur.  The  most  important  and  diagnostic  group  of 
symptoms  may  be  considered  to  be: 

1.  The  Sensory  Manije stations. — The  pain  in  children  is  apparently 
of  a  very  agonizing  character  and  may  be  referred  to  any  part  of  the 
body.  It  is  usually  associated  with  hyperesthesia  so  intense  over  the 
part  affected  that  the  slightest  touch  of  cotton  will  cause  the  patient  to 
cry  out.  The  hyperesthesia,  while  most  intense  over  the  seat  of  pain, 
may  be  present  to  a  lesser  degree  over  one-half  of  the  body,  or  may  be 
localized  in  regular  or  fantastic  forms  to  an  extremity  or  portions  of  the 
trunk.  I>ike  the  anesthetic  disturbances,  it  does  not  correspond  to  the 
anatomical  distribution  of  the  nerve  supplying  the  part,  and  this  fact, 
together  with  its  exaggeration  as  compared  with  the  tenderness  of 
inflammatory  or  other  organic  conditions  will  usually  stamp  its  functional 
character.  Anesthesia  is  of  much  more  frequent  occurrence  and  follows 
the  same  rules.  In  rare  cases  there  may  be  universal  anesthesia  of  the 
skin  and  the  superficial  mucous  membranes,  the  cornea,  however,  being 
practically  never  involved.  A  pin-prick  over  the  anesthetic  areas  is 
usually  not  followed  by  bleeding.  In  rare  cases  there  may  be  other 
vasomotor  disturbances,  such  as  local  or  extensive  edema.  In  one 
case  a  circumscribed  firm  edema  of  the  popliteal  space  associated  with 
a  band  of  hyperesthesia  about  the  knee  and  anesthesia  of  the  leg  below 
the  knee  was  mistaken  for  a  tumor  formation. 

2.  Motor  Manijestations. — These  are  usually  associated  with  either  of 
the  sensory  disturbances  above  described  in  the  part  affected.  Hysterical 
paralysis  may  affect  an  individual  group  of  muscles,  as  the  muscles  of 
the  larynx  and  produce  aphonia;  more  commonly  an  entire  extremity 
may  be  affected,  or  that  they  may  be  a  hemiplegic  type.  The  face,  as 
a  rule,  is  not  involved.  Very  rarely  a  quadriplegia  may  be  present. 
The  reflexes  are  always  present,  although  it  may  be  necessary  to  distract 
the  attention  of  the  child  before  they  can  be  elicited.  As  a  rule,  the 
reflexes  are  quick.  Although  anesthesia  may  be  present,  pain  may  also 
be  complained  of,  and  tenderness  to  pressure  may  be  present  over  the 
muscles  or  nerves.  The  presence  of  the  reflexes,  the  histor}"  of  the  onset, 
and  the  influence  of  suggestion  will  separate  this  paralysis  from  that  due 
to  neuritis  or  organic  disease  of  the  brain.  Hysterical  contracture  or 
hysterical  spasm  may  likewise  affect  a  group  of  muscles,  an  entire 
extremity,  or  several  extremities.  It  is  also  associated  with  the  sensory 
disturbances,  and  likewise  yields  to  suggestion.  Hysterical  tremors  or 
gross  jerkings  may  affect  a  single  member  or  be  widespread  over  the 
entire  body.  They  are  usually  rh}i;hmical  in  character,  although  they 
may  assinne  any  form,  but  do  not,  as  a  rule,  follow  the  type  of  any  of 
the  organic  affections,     A  combination  of  contracture  of  some  muscleg 


878  DISEASES  OF   THE  XERVOUS  SYSTEM 

associated  with  relaxation  of  others  in  the  abdominal  region  produces 
the  false  or  j)hantoni  tumors.    These  disappear  under  ether. 

The  hysterieal  convulsion  usually  affects  all  the  voluntary  nuiscles 
at  one  time  or  other.  While  the  French  clinicians  have  described  a 
regular  series  of  psychic  and  motor  events  during  the  course  of  the 
convulsion,  these  are  more  the  result  of  suggestion  than  of  any  innate 
tendency  to  follow  a  definite  clinical  picture.  The  convulsions  may 
follow  any  form;  they  may  be  brought  on  by  excitement  or  emotion  or 
occur  spontaneously,  but  usually  in  the  presence  of  persons  from  whom 
sympathy  may  be  expected.  A  sudden  tetanic  spasm,  during  which  the 
body  is  highly  arched,  the  patient  perfectly  conscious  or  apparently 
unconscious,  but  receiving  impressions  from  without,  with  respirations 
normal  or  jerky  in  character,  may  be  the  only  manifestation.  This, 
however,  is  usually  followed  by  wild  cries,  irregular  jerkings  of  the  arms 
or  legs,  or  at  times  clawing  or  swimming  movements.  After  the  attack 
passes  off  the  patient  remains  in  an  excited  state,  but  does  not  fall  into 
the  sound  sleep  of  general  epilepsy.  Patients  stationed  in  an  epileptic 
ward  of  a  general  hospital,  where  they  may  observe  real  epilej)tic  fits, 
present  in  their  own  convulsions  a  picture  that  can  be  easily  distinguished 
from  true  epilepsy.  There  is,  as  a  rule,  no  real  loss  of  consciousness 
and  the  jerkings  do  not  follow  the  flexor  and  extensor  type.  The  tongue 
is  never  bitten  nor  is  the  bladder  evacuated  during  the  hysterical  con- 
vulsion, with  a  possible  exception  of  those  cases  where  the  repeated 
questioning  of  the  examiner  along  these  lines  suggest  to  the  hysterical 
patient  the  importance  of  such  facts  in  diagnosis.  The  pupils  are 
normal  during  the  hysterical  convulsion.  It  must  be  remembered, 
however,  in  this  connection  that  hysterical  outbreaks  may  follow  a  true 
epileptic  seizure. 

3.  Visceral  Symptoms. — Inability  to  swallow,  due  to  an  hysterical 
spasm  of  the  esophagus,  can  be  easily  differentiated  from  true  stricture  by 
the  passage  of  a  full-size  bougie.  Hysterical  hiccough  may  occiu*  alone  or 
be  associated  with  aphonia  or  cyanosis.  The  swallowing  of  air  asso- 
ciated with  either  tremendous  distention  of  the  abdomen  or  prolonged 
belching  attacks  occasionally  occurs,  and  may  be  associated  with  hys- 
terical convulsions.  Hysterical  cough  with  hemoptysis,  anorexia,  and 
loss  of  weight  has  been  mistaken  for  pulmonary  tuberculosis. 

Hysterical  anorexia  and  hysterical  vomiting  may  lead  to  marked 
emaciation.  Hysterical  diarrhea  is  not  infrccjuent.  Bradycardia  or 
more  frequently  tachycardia  may  be  associated  with  intense  precordial 
pain. 

4.  Mental  Symptojns. — In  combination  with  any  of  the  above  group 
of  symptoms  an  emotional  atmosphere  surrounds  the  patient  which  is 
very  characteristic.  Craving  for  sympathy  is  rarely  a  verbal  recital  of 
symptoms  such  as  met  with  in  neurasthenia,  but  rather  a  demand  by 
action  such  as  causeless  crying  attacks,  expression  of  intense  pain, 
anxiety  or  fear,  or  some  of  the  above  motor  manifestations  at  an  opportime 
moment.  A  nervous  irritability  associated  with  laughing  or  crying 
spells  may  become  so  marked  as  to  lead  to  distinct  mental  alienation.  The 


THE   CONVULSIVE   DISORDERS  OF   CHILDHOOD  879 

hysterical  insanity  is  merely  an  accentuation  of  intense  emotion  and 
excitement,  and  may  be  either  very  active  or  be  associated  with  such 
depression  as  to  lead  to  simulated  or  real  attempts  at  suicide. 

Diagnosis. — The  main  points  of  a  diagnosis  have  been  considered 
under  the  individual  symptoms.  Hysteria  should  never  be  diagnosed 
until  organic  disease  has  been  entirely  excluded  or  the  organic  element 
dissociated  from  the  functional  manifestations.  The  previous  history  of 
the  case  and  the  influence  of  suggestion  in  controlling  individual  symp- 
toms are  the  most  important  factors  in  making  the  diagnosis.  While  the 
hysterical  manifestations  closely  resemble  organic  disease  there  is  always 
something  atypical,  and  the  exaggeration  alone  is  usually  sufficient  to 
call  the  attention  to  the  possibility  of  hysteria,  which  may  be  confirmed 
by  the  sensory  manifestations.  In  childhood  more  than  at  any  other 
time  of  Hfe  do  we  meet  with  monosymptomatic  hysteria.  In  rare  cases 
it  may  be  even  necessary  to  hypnotize  the  patient  in  order  to  dispel  a 
paralysis,  a  tremor,  or  contracture. 

Treatment. — To  protect  children  of  a  nervous  temperament  from  the 
development  of  hysteria  and  allied  functional  disorders,  great  care  should 
be  used  in  the  education  of  the  child.  This  refers  as  much  to  home 
training  as  to  school  education.  A  firm  discipline  tempered  with  kind- 
ness is  very  necessary  in  both  places.  Regular  methods  of  life,  with 
plenty  of  out-of-door  exercise;  a  good,  nutritious  diet,  with  little  meat 
and  no  tea  or  coffee,  should  be  insisted  upon.  Care  should  be  used, 
especially  in  growing  girls,  to  prevent  overwork  at  school  and  to  relieve 
the  child  as  far  as  possible  from  the  worry  of  examinations.  When 
hysteria  develops  it  may  be  necessary  to  treat  both  the  individual  attacks 
and  the  disease  itself.  In  the  milder  cases  a  change  of  living  atmosphere 
of  the  patient,  under  the  guidance  of  a  trained  nurse  or  a  companion  at 
some  country  resort  away  from  the  influence  and  sympathy  of  over- 
anxious relatives  and  friends,  is  all  that  is  necessary.  In  all  cases  under- 
lying organic  or  functional  disturbances  of  the  viscera  should  be  care- 
fully sought  for  and  eliminated.  Constipation  should  be  relieved  by 
appropriate  remedies,  and  proper  sleep  secured  by  the  use  of  bromides, 
trional,  etc.  In  all  but  the  most  severe  cases  I  have  found  a  modified 
rest  treatment  either  at  home,  or,  better,  at  some  health  resort,  the  most 
beneficial  method  of  treatment.  The  regulations  once  established  should 
be  absolutely  insisted  upon.  A  physician  should  see  the  patient  every 
day  or  every  second  day,  and  carefully  inquire  into  the  details  of  the 
treatment.  Directions  as  far  as  possible  should  be  written  out  in  detail. 
Where  directions  are  simply  given  and  no  further  inquiry  made  it  may 
be  safe  to  assume  in  nearly  every  case  that  violations  will  frequently 
occur. 

Apart  from  the  beneficial  results  to  the  exhausted  and  unstable 
nervous  system,  the  discipline  and  moral  encouragement  by  the  physician 
are  of  value  in  strengthening  a  weakened  will-power.  Twelve  hours 
rest  at  night  should  be  insisted  upon.  It  is  quite  immaterial  whether 
the  patient  sleeps  all  this  time  or  not.  At  least  two  hours'  rest  in  bed 
in  the  middle  of  the  day,  at  a  definite  prescribed  hour,  is  necessary  to 


880  DISEASES  OF   THE  NERVOUS  SYSTEM 

overcome  the  fatigue  developed  during  the  day  and  to  give  the  nervous 
system  a  chance  to  recuperate.  The  exercise  should  be  carefully  regu- 
lated and  selected  in  such  a  way  as  to  give  as  nuicli  pleasure  as  possible 
with  the  least  excitement.  In  the  severe  cases,  and  in  those  in  which  the 
muscles  are  soft  and  flabby,  well-regulated  massage  should  precede  the 
out-of-door  exercises.  Electricity  is  also  of  value  both  as  a  stimulant 
tonic  and  to  secure  a  proper  condition  of  the  muscles.  All  of  the  regu- 
lations should  be  so  arranged  at  fixed  intervals  as  to  keep  the  patient 
occupied  and  to  keep  the  mind  as  far  as  possible  away  from  the  local 
symptoms  and  the  patient  herself.  For  the  indivitlual  symptoms,  a 
suggestion  that  there  is  a  constant  improvement  will  usually  be  all  that 
is  necessary.  If  the  patient's  mind  is  not  too  nuich  concentrated  on  any 
individual  symptom,  it  is  nuicli  better  to  disregard  treatment  in  that 
direction  until  the  systematic  treatment  is  thoroughly  developed  and 
the  confldence  of  the  patient  secured.  A  firm,  hopeful,  confident  attitude, 
with  a  proper  tactful  dispensation  of  sympathy  or  harshness,  are  necessary 
qualifications  for  the  physician  to  secure  results  in  the  handling  of  these 
cases.  The  relatives  and  friends  of  the  patient  should  either  not  be 
permitted  to  see  the  patient  at  all  or  only  at  intervals,  and  then  as  a 
reward  for  the  control  of  some  particular  manifestation  of  the  disease. 
Overfeeding  may  be  necessary  in  cases  of  low  nutrition,  and  a  very 
careful  discrimination  in  the  use  of  massage,  exercise,  and  dieting  in 
flabby,  fat  individuals.  Sedative  tonics  in  conditions  of  excessive  nervous 
irritability  are  often  indicated.  I  have  found  the  following  prescriptions 
of  considerable  value: 

Jfc— Sodii  bromid 0.03  to  1.3  gm.  (gtt.  v  to  xx). 

Tr.  nticis  vom 0.03  to  1.0  c.c.  (gtt.  v  to  xv). 

Tr.  cinchonie  comp 2.00  c.c.  (3ss). 

Aq.  dest ad  15.00  c.c.  (5ss). 

M.  et  sig.  4  c.c.  (5j)  t.  i.  d. 

Jt;— Sodii  hromid 0.03  to  1.3  gm.        (gr.  v  to  xx). 

Elix.  Valerianae  amraoniae         ....    2  to  4  c.c.  (5ss  to  5j). 

M.  et  sig.  4  c.c.  (.jj)  t.  i.  d. 

Valerian,  asafetida,  paraldehyde,  and  other  nauseous  drugs  are  fre- 
quently used,  but  are  mainly  of  value  on  account  of  their  disagreeable 
taste.     In  anemic  conditions  the  iron  pre})arations  are  serviceable. 

In  very  .severe  obstinate  ca.ses  the  full  rest  treatment  as  outlined  by 
Weir  Mitchell  gives  the  best  results.  The  patient  should  never  be 
treated  at  home,  but  removed  to  a  hospital  or  some  institution  where 
absolute  .seclusion  in  a  quiet  room  can  be  secured.  An  intelligent  nurse 
familiiir  with  the  treatment,  or,  better,  a  nur.se  especially  trained  for  it 
and  v--)ngeiiial  to  the  patient,  is  e.s.sential.  Ab.solute  rest  in  bed  without 
even  permission  to  read,  write,  feed,  or  otherwise  care  for  herself  should 
be  insisted  upon.  Ma.ssage,  electricity,  and  overfeeding  are  other 
essentials  of  the  treatment.  The  same  rules  as  to  regularity, system, and 
control  as  above  outlined  in  the  modified  rest  treatment  should  be 
carried  out.  It  may  be  necessary  in  some  cases  to  start  on  the  simple 
milk  diet  and  gradually  add  other  food  as  soon  as  the  system  is  educated 
to  take  care  of  it,    Exclusion  of  visitors  and  even  of  news  of  the  outside 


THE  CONVULSIVE  DISORDERS  OF  CHILDHOOD  881 

world  is  at  first  necessary,  and  later  permitted  according  to  the  rules 
above  laid  down  in  the  modified  treatment.  The  greatest  care  must 
be  used  toward  the  end  of  the  treatment  in  restoring  the  patient  to 
normal  mental  and  physical  surroundings.  The  patient  should  at  first 
be  permitted  to  sit  up  for  a  short  time,  and  this  time  increased  if  no 
untoward  symptoms  are  produced.  Fatigue,  nervousness,  and  insomnia 
are  indications  that  too  much  is  being  attempted.  The  same  is  true 
when  the  patient  begins  to  walk  and  to  take  out-of-door  exercises. 
Responsibility  of  gradually  thinking  for  herself  and  of  deciding  as  to 
other  responsibilities  of  life  should  be  gradually  shifted  from  the  physician 
to  the  patient  until  a  normal  condition  obtains.  A  regular  method  of 
life  should  be  insisted  upon  for  a  long  time.  The  education  of  a  proper 
mode  of  living  and  of  the  care  of  the  nervous  system  are  not  the  least  of 
the  benefits  to  be  expected  from  this  treatment. 

^Yhile  hysteria  is  prone  to  recur  in  those  who  have  once  thoroughly 
developed  the  disease,  normal  nervous  health  rests  to  a  great  extent  in 
the  hands  of  the  patient,  and  if  she  has  profited  by  the  lessons  learned, 
and  the  influence  of  rest,  regularity,  and  system  in  keeping  the  nervous 
system  at  its  highest  point  of  efficiency,  thus  avoiding  any  unnecessary 
strain,  there  is  little  likelihood  in  the  majority  of  cases  of  a  return  of 
the  affection. 

NEURASTHENIA. 

While  Neurasthenia  is  an  uncommon  condition  in  childhood,  mild 
and,  rarely,  more  severe  forms  are  occasionally  met  with.  It  usually 
develops  in  children  of  a  high-strung  nervous  temperament  who  are 
being  pushed  too  fast  at  school,  associated  with  the  worry  of  an  oncom- 
ing examination  or  possibly  of  some  home  affliction.  It  may  follow  an 
influenza.  Masturbation  in  growing  children  may  be  an  important 
factor.  Eye  strain  is  frequently  present.  It  has  also  been  observed  in 
infancy  where  a  baby  has  been  kept  agitated  and  disturbed. 

Symptomatology.— Mental  and  physical  fatigue  are  the  predominating 
symptoms.  The  child  becomes  moody,  introspective,  and  in  a  child 
approaching  adult  life  suicidal  tendencies  may  be  manifested.  Obses- 
sions with  impulses  to  do  a  wrong  thing  or  to  satisfy  a  morbid  desire 
may  be  associated  in  the  severe  forms  with  loss  of  memory ,_  failure  to 
concentrate  the  attention,  and  intense  excitability  or  depression.  ^  Pain 
in  the  head  or  back  may  be  complained  of,  but  there  are  no  objective 
disturbances  of  sensation.  A  subjective  sensation  of  cold  water  running 
over  the  body  or  ants  crawling  over  the  skin  may  be  present.  While 
the  reflexes  are  usually  quick,  there  are  no  paralyses  or  other  motor 
manifestations  other  than  fatigue  and  a  fine  tremor  after  excitement 
or  mental  and  physical  exertion. 

Diagnosis.— An  'incipient   tuberculosis,    an   unsuspected    cardiac   or 
renal  disease  is  so  frequently  mistaken  for  neurasthenia   that  we  are 
only  justified  in  making  this  diagnosis  after  the  most  careful  examina- 
tion and  exclusion  of  organic  disease. 
56 


882  DISEASES  OF    THE   XERVOl'S  SYSTEM 

Treatment. — The  care  of  the  child,  the  hygiene  of  its  Ufe,  and  the 
treatment  of  the  disease  do  not  differ  from  that  above  outHned  for 
hysteria.  An  infant  shonld  be  allowed  to  lead  a  perfectly  normal  life 
without  disturbance  by  relatives  and  friends. 


THOMSEN'S  DISEASE. 

This  mav  be  considered  to  be  an  hereditary  disease  affecting  several 
members  of  the  same  family  and  is  called  Myotonia  Congenita.  In 
Thomsen's  family  the  affection  could  be  traced  through  five  generations. 
In  some  cases  the  heredity  is  missing,  and  isolated  individual  members 
of  a  family  may  be  affected.  Sporadic  cases  presenting  the  same  clinical 
picture  are  occasionally  met  with.  Transitory  conditions  resembling 
this  disease  also  occur.  It  is  a  rare  condition,  but  I  have  seen  three 
cases  in  European  clinics,  and  one  case  which  came  under  my  own 
observation. 

Pathology. — The  nervous  system  so  far  as  has  been  studied  has  shown 
no  pathological  lesions.  Hypertrophy  of  the  primitive  muscle  fibres 
with  multi|)lication  of  the  muscle  nuclei  has  been  found. 

Symptomatology. — The  disease  develops  early  in  chiklhood  and  is 
manifested  by  a  rigidity  of  the  muscles  when  a  voluntary  movement  is 
attempted.  If  the  child  be  in  a  sitting  jx)sture  and  attempts  to  get  uj) 
and  walk,  the  muscles  of  the  leg  and  back  become  rigid,  and  it  is  only 
after  repeated  attempts  at  motion  that  sufficient  relaxation  occiu's 
to  permit  free  movement.  With  each  successive  movement  more  free- 
dom is  gain(Ml,  until  after  several  steps  a  normal  condition  obtains. 
The  same  condition  is  present  in  the  arms  and  rarely  in  the  face  and 
laryngeal  muscles.  Plxposure  to  cold  and  emotional  excitement  accent- 
uate the  symptoms.  IMental  weakness  has  been  noticed.  The  muscles 
are  normal  or  overdeveloped,  but  are  usually  weak  in  comparison  to 
the  volume  of  muscle  tissue.  As  adult  life  is  approached  a  pseudo- 
hypertrophic condition  with  deposits  of  fat  between  the  muscle  fibres 
and  marked  motor  weakness  may  develop.  A  tap  on  the  muscles  pro- 
duces a  local  spasm,  which  lasts  several  minutes  before  relaxation 
occurs.  The  same  is  true  of  the  reaction  of  both  muscle  and  nerve  to 
electric  currents.  There  is  no  known  treatment  that  has  much  influ- 
ence on  the  course  of  the  disease.    Spontaneous  arrest  has  been  noted. 

Eulenberg  has  given  the  term  congenital  paramyotonia  to  a  modifi- 
cation of  the  above  disease.  It  is  also  hereditary  in  character,  of  a 
family  nature,  and  manifested  by  a  tonic  spasm  lasting  from  a  few 
minutes  to  several  hoiu's,  brought  on  by  exposure  to  cold.  There  is  an 
absence  of  increased  mechanical  excitability  and  also  of  the  myotonic 
electric  reaction. 


FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM       883 


PARAMYOCLONUS  MULTIPLEX. 

This  is  also  an  hereditary  affection  and  is  one  of  the  rarest  of  the 
motor  diseases,  although  not  so  rare  as  Thomsen's  disease.  Males  are 
more  frequently  affected.  Intense  fright,  straining,  or  other  emo- 
tional disturbance  has  been  blamed  for  it.  Rapid  rhythmical  con- 
tractions, varying  from  fifty  to  one  hundred  and  fifty  to  the  minute, 
affecting  individual  muscles  or  groups  of  muscles  and,  as  a  rule, 
symmetrical  muscles,  are  the  chief  clinical  manifestations.  Tremor  of 
the  muscles  may  be  present  during  the  intervals  between  the  grosser 
clonic  movements.  The  face  muscles  are  usually  exempt  and  in  this 
respect  it  is  unlike  chorea  or  the  other  clonic  spasms.  The  muscle  con- 
tractions are  so  rapid  and  of  such  short  duration  that  the  movements 
in  the  extremities  produced  are,  as  a  rule,  not  marked.  There  is  no 
change  in  the  electric  excitability.  It  is  more  frequent  in  adult  life, 
although  it  may  occur  in  children.  If  associated  with  epilepsy  it  is  termed 
myoclonus  epilepsy.  It  is  differentiated  from  Sydenham's  or  electric 
chorea  by  the  rapidity  of  the  contractions,  the  absence  of  the  irregular 
movements  of  the  extremities,  and  the  course  of  the  disease.  A  very  few 
cases  have  been  entirely  cured.    The  prognosis  in  most  cases  is  serious. 

Treatment. — Alterative  tonics,  nerve  sedatives,  increase  of  the  body 
nutrition,  and  regulated  gymnastic  exercises  sometimes  do  good. 


NOCTURNAL  ENURESIS  IN  NERVOUS  DISORDERS  OF  CHILDHOOD. 

Children  otherwise  of  good  habit  during  the  day  not  infrequently 
manifest  disturbances  of  micturition  during  the  night.  This  usually 
occurs  during  the  soundest  sleep  and  this  in  itself  may  be  sufficient  in 
some  cases  to  account  for  it.  In  other  cases  it  is  due  to  faulty  training 
and  an  aversion  on  the  part  of  the  child  to  permit  an  interruption  of  its 
sleep.  In  rare  cases,  and  this  is  especially  true  of  those  in  which  night 
terrors  are  associated,  it  may  be  a  manifestation  of  an  oncoming  or 
developed  epilepsy.  In  the  latter  cases  the  tongue  may  be  bitten,  or 
headache  or  drowsiness  be  present  during  the  following  day.  While 
night  terrors  may  be  merely  the  manifestation  of  the  fear  engendered 
upon  waking  from  a  sound  sleep  by  a  frightful  dream  it  should  be  borne 
in  mind  that  this  condition  is  most  frequently  present  in  children  of  a 
nervous  temperament  and  of  neurotic  heredity.  It  occurs  usually 
between  the  third  and  eighth  year  of  life  and  may  persist  even  to  adult 
life.  The  history  of  night  terrors  in  children  occurs  so  frequently  in  the 
history  of  epileptic  children,  and  in  those  who  have  been  cured  of  the 
convulsive  habit,  that  the  relation  of  enuresis  and  night  terrors  to 
epilepsy  should  always  be  borne  in  mind.  Other  factors  are  mentioned 
in  the  section  relating  to  the  Diseases  of  the  Genitourinary  System. 

Treatment. — Although  at  times  a  very  stubborn  condition  it  will,  in 
children  of  normal  mentality,  yield  to  careful  training.    Salt  and  salty 


884  DISEASES  OF    THE   XERVOUS  SYSTEM 

foods  sliould  he  carefully  eliminated  t'roiii  the  diet,  and  liquids  exeluded 
after  the  middle  of  the  day.  The  time  of  tlie  oeeurrenee  of  the  mictu- 
rition should  be  carefully  noted  and  the  child  awakened  from  half  an 
hour  to  an  hour  l)efore  this  time  and  the  bladder  evacuated.  Where 
more  than  one  evacuation  of  the  bladder  occurs  during  the  night, 
the  child  should  be  awakened  at  fre(|uent  intervals.  If  drugs  be 
us(>d  the  tincture  of  belladonna  should  be  given  in  ascending  doses 
until  physiological  results  are  obtained.  It  is  useless  in  small  doses  or 
where  given  alone  without  the  assistance  of  the  above  directions.  When 
night  terrors  are  present  the  bromides  are  indicated.  The  hygienic  regi- 
men outlined  under  Epilepsy  should  be  carrietl  out  if  there  is  even 
suspicion  of  a  beginning  epilepsy.  Corporal  punishment  fre(|ueiitly 
produces  results  opposite  to  that  desired.  The  treatment  of  inconti- 
nence of  urine  due  to  myelitis,  Pott's  disease,  spinal  tumor,  encepha- 
litis, etc.,  is  given  under  these  diseases.  In  retarded  mental  develop- 
ment, idiocy,  etc.,  treatment  is  practically  useless. 


CHAPTEK   XXXVI. 

ORGANIC  NERVOUS  DISEASES— DISEASES  OF  THE  NERVES  AND 
SPINAL  CORD— ABIOTROPHIC  DISEASES. 

ORGANIC  NERVOUS  DISEASES. 
DISEASES  OF  THE  PERIPHERAL  NERVES. 

Inflammation  of  the  nerves,  Neuritis,  may  be  localized  to  a  single 
nerve,  it  may  affect  several  nerves,  or  it  may  involve  almost  if  not  all  of 
the  peripheral  nervous  system.  To  the  two  latter  forms  is  given  the 
tei'm  multiple  neuritis. 

Etiology. — While  idiopathic  forms  of  neuritis  have  been  described 
and  exposure  to  cold  and  wet  given  as  a  cause,  it  may  be  said,  as  a  general 
rule,  that  if  traumatism  or  pressure  on  the  nerves  be  excluded  it  may  be 
assumed  that  the  neuritis  is  caused  by  an  underlying  intoxication  or 
the  presence  of  some  micro-organism  in  the  nerve. 

Pathology. — From  a  pathological  standpoint  two  distinct  forms  of 
neuritis  may  be  recognized — a  parenchymatous  and  an  interstitial.  Paren- 
chymatous neuritis  is  a  toxic  degeneration  affecting  the  axis  cylinder 
and  its  myelin  protecting  sheath,  and  with  no  changes  or  very  minor 
changes  in  the  connective  tissue.  This  condition,  the  best  type  of  which 
is  seen  in  lead  palsy,  lacks  the  characteristic  manifestations  of  an  inflam- 
matory process  and  is  more  strictly  a  degeneration  than  an  inflamma- 
tion. There  is  no  elevation  of  temperature,  no  redness  of  the  nerve, 
and  the  bloodvessels  of  the  interstitial  tissue  are  neither  surrounded 
by  or  infiltrated  by  hemorrhages  or  small  cells.  In  a  well-developed 
case  the  myelin  becomes  swollen  and  degenerates  into  small  globules 
of  fat,  the  axis  cylinder  becomes  granular,  and  is  finally  broken  down. 
In  progressive  cases  these  materials  are  absorbed  and  nothing  may 
remain  but  a  colmective-tissue  band;  in  other  cases  the  process  may 
stop  at  any  one  of  the  above  stages,  followed  by,  first,  regeneration  of 
the  axis  cylinder,  and  later  of  the  myelin  sheath  from  the  nuclei  of  the 
connective-tissue  sheath  of  Schwann.  This  condition  of  the  nerve  is 
the  same  as  that  seen  after  cutting  off  the  blood  supply,  after  prolonged 
pressure,  or  destruction  of  the  cells  of  the  anterior  horn  of  the  spinal 
cord.  We  most  frequently  meet  with  this  form  of  degeneration  in  the 
chronic  intoxication  of  lead,  and  in  certain  infectious  processes  such  as 
tuberculosis,  diphtheria,  etc. 

In  true  inflammation  of  the  nerves,  interstitial  neuritis,  the  nerve  is 
swollen,  congested,  of  a  thicker  and  redder  color,  as  a  rule,  although 
in   advanced  stages  it  may  be  yellow  from  the  presence  of    pus  and 

(  885  ) 


836  DISEASES  OF  THE  NERVOUS  SYSTEM 

serum.  On  microscopic  examination,  besides  the  changes  above  noted 
in  parenchymatgus  degeneration,  there  is  a  marked  congestion  of 
the  bloodvessels,  capillary  or  diffused  hemorrhage,  and  an  outwandering 
of  leukocytes,  all  of  which  exert  a  toxic  anil  pressure  influence  on 
the  nerve  fibres.  Above  and  below  the  point  of  active  inflammation 
deo-eneration  of  the  nerve  fibres  in  a  distal  direction  from  its  nutritive 
cell  connection  may  be  seen.  Here  again  the  process  may  go  on  to 
complete  degeneration,  or  it  may  stop  with  complete  or  partial  regener- 
ation at  any  stage  of  the  process.  The  process  of  regeneration  is,  as 
a  rule,  verv  slow,  varying  from  six  weeks  in  the  milder  types  to  as  many 
months  in  "the  more  severe  forms.  Injuries  to  nerves  may  set  up  an 
inflanunatory  process,  or  an  injury  to  the  nerve  fibres  may  produce 
a  secondarv  degeneration  without  evidence  of  inflammatory  degener- 
ation, giving  a  picture  similar  to  that  of  parenchymatous  degeneration. 
This  process  may  be  slight  or  advance  to  complete  degeneration.  The 
latter  occurs  where  scar  tissue  develops  in  such  a  way  as  to  completely 
interfere  with  the  transmission  of  impulses  or  the  regeneration  of  the 
axis  cylinder.  The  same  is  true  of  the  effects  of  tumors  of  nerves  or 
the  results  of  the  inclusion  of  a  nerve  in  the  callus  from  a  fracture. 

Symptomatology.  1.  Parenchymatous  Neuritis. — The  type  of  this 
form  of  neuritis  is  that  seen  in  diphtheria.  There  is  no  fever,  pain,  or 
tenderness  along  the  course  of  the  nerve.  The  only  symptom  present 
is  a  paralysis  in  the  distribution  of  the  nerve  affected,  which  is  usually 
complete  and  may  be  associated  with  loss  of  sensation  in  the  skin  area 
supplied.  Trophic  influence  may  also  be  affected,  and  wasting  may 
occur.  In  the  milder  forms  the  sensation  is  not  disturbed.  In  diphtheria 
the  nerves  to  the  palate,  the  extraocular  muscles,  and  those  of  the 
lower  extremity  are  usually  affected.  Prognosis,  except  in  those  cases 
where  the  vagus  is  affected,  is  good,  recovery  usually  taking  place  in 
from  six  weeks  to  six  months.  In  lead  poisoning  the  musculospiral 
nerve  is  usually  affected  on  both  sides,  with  a  resulting  bilateral  wrist- 
drop. 

2.  Interstitial  Xeuritis. — The  toxins  of  the  infectious  fevers  finfluenzft, 
typhoid,  malaria,  bubonic  plague,  pyemia,  syphilis,  leprosy,  beriberi), 
alcohol,  arsenic,  mercury,  zinc,  ether,  bisulphite  of  carbon,  and  cachectic 
states,  such  as  cancer,  are  the  most  common  causes.  The  symptoms 
are  those  of  any  acute  inflammation.  If  the  neuritis  be  sufficiently 
extensive  there  may  be  slight  fever.  When  a  single  nerve  is  affected 
the  symptoms  are  of  course  localized  to  the  distribution  of  this  nerve. 
Pain  is  the  predominating  symptom.  This  may  be  of  a  dull  or  of  an 
intense  staV/V)ing  character.  Tenderness  is  marked  along  the  course 
of  the  nerve  and  not  infrequently  in  the  palsied  muscles.  In  superficial 
nerves  the  nerve  may  be  distinctly  swollen  to  palpation.  The  function 
of  the  nerve  (motion,  sensation,  nutrition)  is  partially  or  completely 
destroyed.  In  the  early  stages  tingling  and  formication  may  be  associ- 
ated with  slight  hyperesthesia;  this  rapidly  gives  way  to  loss  of  sensation 
and  motor  j)aralysis.  The  reflexes  in  the  distribution  of  the  nerve 
affected  are  lost.     I  have  never  seen  a  case  where  I  felt  justified  in 


OR GANIC  NEB,  VO  US  DISEASES  887 

making  the  diagnosis  of  neuritis  with  the  reflexes  normal  or  increased  in 
the  distribution  of  the  affected  nerve.  Trophic  disturbances — wasting 
of  the  muscles,  glossiness  of  the  skin,  local  edema,  defective  or  per- 
verted nutrition  of  the  nails — develop  in  some  cases  early,  in  other  cases 
late  or  not  at  all.  The  trophic  disturbance  is  early  manifested  by  the 
reaction  of  the  muscles  to  the  electric  current.  There  is  complete 
failure  of  reaction  to  the  rapidly  interrupted  current,  and  the  reaction 
to  the  galvanic  current  is  slow  and  vermicular  instead  of  a  normal  quick 
contraction.  This  slow  contraction  is  a  more  positive  and  diagnostic 
sign  than  the  change  in  the  formula.  Instead  of  the  stronger  contrac- 
tion being  obtained  when  the  cathode  is  applied  to  the  affected  muscle 
and  closed,  the  stronger  contraction  is  obtained  when  the  anode  is 
applied.  When  multiple  nerves  are  affected  the  term  multiple  neuritis 
is  employed.  While  alcohol  is  the  most  common  form  of  multiple  neuritis 
met  with  in  the  adult  that  due  to  the  infectious  fevers,  or  the  metallic 
poisons  is  most  common  in  childhood.  In  influenza  all  four  extremities 
may  be  involved  and  the  symptoms  be  associated  with  considerable 
fever.  A  fatal  termination  in  such  cases  may  ensue  from  involvement 
of  the  cardiac  nerves. 

Diagnosis. — The  absence  of  the  reflexes,  the  associated  motor  and 
sensory  paralysis,  the  change  in  the  electric  reaction,  and  the  distribu- 
tion of  the  symptoms  corresponding  to  the  anatomical  distribution  of 
the  nerves  will  usually  make  the  diagnosis.  In  exceptionally  rare  cases 
the  inflammation  may  extend  to  the  spinal  cord,  with  the  production  of 
myelitis.  Disease  of  the  spinal  cord  may  be  excluded  by  the  absence 
of  the  involvement  of  the  bladder  and  rectum,  and  of  marked  sensory 
changes  on  the  trunk.  In  multiple  neuritis  the  tenderness  over  the 
nerves  with  the  preservation  of  the  bladder  and  rectal  function  will 
differentiate  this  disease  from  myelitis. 

Prognosis. — The  prognosis  in  any  given  case  of  neuritis  must  depend 
on  a  careful  study  of  the  local  manifestations  for  some  time.  Where 
the  loss  of  nerve  function  is  complete  and  the  reactions  of  degeneration 
develop  early,  and  where  there  is  a  marked  tendency  of  a  progressive 
type  for  the  muscles  affected  to  fail  to  react  to  increased  quantities 
of  the  galvanic  current,  and  where  other  trophic  manifestations  develop 
early,  the  prognosis  is  grave  for  return  of  function.  If  it  return  at  all 
it  will  only  be  after  many  months  of  careful  and  painstaking  treatment. 
Where  the  electric  reactions  are  only  slightly  disturbed  or  develop 
some  time  (weeks)  after  the  onset  the  prognosis  is  favorable.  In  those 
cases  where  no  change  of  the  electric  reactions  are  noted  return  of 
function  may  be  expected  in  several  weeks. 

Treatment. — Rest  of  the  body  and  absolute  rest  of  the  part  affected 
are  absolutely  necessary.  Any  underlying  intoxication  or  pathological 
lesion  causing  pressure  should  be  removed  as  early  as  possible.  The 
general  body  functions,  and  especially  the  gastroenteric  tract,  should  be 
brought  into  a  normal  condition  as  soon  as  possible  in  order  to  prevent 
any  added  intoxication.  To  relieve  the  intense  pain  phenacetin  in  doses 
of  0.06  to  0.3  gm.  ( 1  to  5  gr.)  or  combined  with  salicylates  is  valuable.     It 


DISEASES  OF  THE  NERVOUS  SYSTEM 

may  be  necessary  in  some  cases  to  use  morphine.  A  single  l)lister  or 
multiple  blisters  alonj;  the  course  of  the  nerve  or  the  application  of 
the  actual  cautery  both  gives  relief  and  has  a  beneficial  infiuence  on 
the  inflammatory  process.  A.s  soon  as  the  acute  inflammatory  symp- 
toms have  subsided  gentle  massage  and  hypodermic  injections  of  strych- 
nine, 0.00012  to  O.OOOG  gm.  (vffo  to  Y^ij  gr.),  into  the  affected  muscles 
should  be  used.  The  galvanic  current  is  also  of  value  in  securing 
restoration  of  function. 


SPECIAL  FORMS  OF  NEURITIS. 

Obstetrical  Palsies. — These  are  most  often  brachial  birth  palsies 
and  are  due  to  tinsion,  secondary  to  the  manipulations  necessary  in 
delivery.  In  all  these  cases  in  which  severe  traction  upon  an  arm  or 
stretching  of  head  to  one  side  (Clark,  Taylor  and  Prout)  is  necessary, 
the  brachial  plexus  is  torn  and  lacerated  at  Erb's  point,  the  junction 
of  the  fifth  and  sixth  cervical  nerves.  In  rare  cases  the  ])aralysis  may  be 
bilateral.  The  degree  of  paralysis  depends  upon  the  extent  and  intensity 
of  the  injury.  The  entire  arm  may  be  c()ni{)letely  paralyzed,  or  uk^'c 
fre(|uently  the  upper  arm  is  paralyzed  with  a  fair  amount  of  function 
retained  in  the  forearm  and  hand.  This  form  of  paralysis  is  most  fre- 
(juently  mistaken  for  paralysis  due  to  brain  lesions.  The  paralysis  of 
the  cerebral  palsies  is  spastic  in  type,  whereas  this  type  of  paralysis  is 
flaccid,  with  lost  reflexes  and  reactions  of  regeneration. 

The  prognosis  depends  upon  the  same  rules  as  given  above  in  cases 
of  neuritis. 

Treatment.— Treatment  is  by  massage  and  electricity,  carried  out  as 
soon  as  is  practicable.  If  after  a  year  the  paralysis  is  persistent  resec- 
tion of  the  nerves  may  be  required  (p.  <S90j. 

A  peripheral  paralysis  may  be  prenatal  in  type,  and  possibly  due 
to  a  malposition  of  the  fetus  in  utero.  The  paralysis  in  a  case  of  Dr. 
Burk's  was  present  at  birth  and  associated  with  clubhands  and  clubfeet. 
The  reflexes  were  present  in  the  forearms,  but  were  absent  in  the  upper 
arms.  This  was  probaljly  a  case  of  plexus  palsy,  due  to  a  malposition 
of  the  fetus  in  which  pressure  was  exerted  on  the  brachial  plexus  on  both 
sides. 

Facial  paralysis  has  been  produced  by  the  pressure  of  the  forceps  on 
the  facial  nerve  (vide  infra). 

Facial  Palsy  (Bell's  Palsy). — Paralysis  due  to  lesions  of  the  seventh 
nerve  may  develop  at  any  time  of  childhood  and  are  due  to  the  same 
causes  as  in  adult  life.  The  most  frerpient  of  these  is  exposure  and  is 
commonly  termed  rheumatic  palsy.  "^Phis  form  of  the  disease  is  prob- 
ably due  to  some  infection.  Two  of  the  eighteen  cases  which  came 
under  my  observation  during  the  past  year  were  children.  It  usually 
follows  exposure  to  a  draught,  although  no  such  histoi^  may  be  present, 
and  outside  of  a  pharyngitis  or  tonsillitis  no  evidence  of  rheumatism  is 
usually  present.     The  next  most  frequent  cause  is  disease  of  the  middle 


OBGANIO  NERVOUS  DISEASES 


889 


ear.  This  may  be  simply  an  involvement  of  the  nerve  by  a  purulent 
process,  or,  more  frequently,  it  follows  operation  on  the  middle  ear  with 
traumatism  to  the  nerve.  The  third  and  least  frequent  cause  is  the 
involvement  of  the  seventh  nerve  within  the  skull  by  meningitis,  fracture 
at  the  base,  inflammations,  tumors  or  abscess  of  the  pons  between  the 
nucleus  of  the  nerve  and  its  exit. 

Symptomatology. — Inasmuch  as  the  seventh  nerve  is  purely  a  motor 
nerve  to  the  muscles  of  the  face,  the  symptoms  are  merely  a  more  or  less 
complete  paralysis  of  motion,  with  secondary  wasting  on  one  side  of  the 
face.  The  child  is  unable  to  close  the  eye,  every  attempt  being  asso- 
ciated with  an  upward  movement  of  the  eyeball  (Bell's  symptom). 
The  forehead  is  flat  on  the  affected  side,  and  there  is  an  absence  of 
WTinkling  when  the  brows  are  elevated.    The  mouth  droops  and  there 


Fig. 176 


Facial  paralysis.    (Bell's  paralysis.) 

is  an  absence  or  flattening  of  the  nasolabial  fold.  There  may  be  a  spot 
of  tenderness  at  the  exit  of  the  nerve  from  the  skull.  In  rare  cases  pain 
may  be  complained  of,  but  this  will  usually  be  found  to  be  due  to  an 
involvement  of  the  fifth  nerve,  and  sensitive  areas  will  be  present  at  the 
exit  points  of  this  nerve.  In  severe  cases  degeneration  of  the  muscles 
will  occur,  and  where  recovery  of  function  does  not  take  place  a  secondary 
contraction  of  the  affected  muscles  may  pull  the  face  toward  the  affected 
side  in  such  a  way  as  to  give  the  appearance  as  if  the  opposite  side  were 
paralyzed.  In  niild  cases  the  symptoms  will  be  more  plainly  brought 
out  by  forcible  closure  of  the  eyes  or  by  getting  the  child  to  laugh,  pout, 
or  show  the  teeth.     (See  Fig.  176.) 

Diagnosis. — From  lesions  in  the  brain  above  the  nucleus  Bell's  palsy 
can  easily  be  differentiated  by  the  absence  of  any  symptoms  other  than 


890  DISEASES  OF  THE  NERVOUS  SYSTEM 

tliose  referable  to  the  face.  In  cerebral  lesions  a  paralysis  of  an  arm  or 
leg,  sciisorv  (listurl)anc(\s,  and  other  cranial  nerve  lesions  will  l)e  present. 

Prognosis. — In  cases  secondary  to  operative  attacks  on  the  ear  or  the 
mastoid  the  paralysis  is  usually  complete  and  permanent.  The  majority 
of  cases  of  the  rheumatic  class  get  well  after  a  longer  or  shorter  period. 
Prognosis  can  be  fairly  accurately  made  by  a  study  of  the  electric 
reactions.  If  the  nniscles  react  with  a  faradic  current  at  the  end  of  a 
week,  and  if  the  reaction  to  the  galvanic  current  is  cpiick  without  change 
of  the  formula,  complete  recovery  within  six  weeks  may  be  expected.  If, 
on  the  other  hand,  faradic  irritability  be  lost  and  the  reaction  to  the 
galvanic  current  be  slow,  but  where  the  cathodal-closing  contraction  is 
still  greater  or  at  least  equal  to  the  anodal-closing  contractiou,  recovery 
need  not  be  expected  in  less  than  six  weeks  and  will  probably  take 
between  three  and  six  months.  In  those  cases  where  the  contraction  is 
very  slow  and  where  the  anodal-closing  contraction  is  greater  than  the 
catiiodal-dosing  a  few  days  after  the  onset,  and  where  larger  quantities 
of  the  galvanic  current  are  necessary  to  produce  a  contraction  from  day 
to  day,  an  unfavorable  prognosis  should  be  given,  and  if  function  returns 
at  all  it  will  be  only  after  one  or  two  years  of  careful  and  painstaking 
treatment. 

In  some  cases  the  superior  distribution  regains  its  function  first,  ])ut 
in  the  larger  number  function  returns  first  in  the  lower  distribution  and 
later,  if  at  all,  in  the  superior  distribution. 

Treatment. — The  milder  cases  recover  rapidly  without  any  special 
treatment.  In  the  severer  cases  a  blister  or  other  form  of  counterirrita- 
tion  miflway  between  the  angle  of  the  jaw  and  the  mastoid  process 
should  be  applied.  Electricity  should  not  be  begun  ff)r  at  least  a  week 
after  the  onset.  A  mild  galvanic  current  sufficient  to  secure  a  mild  con- 
traction of  the  affected  muscles  should  be  used.  The  smallest  possible 
current  to  secure  contractions  should  be  employed,  and  should  never 
be  so  strong  Ji.s  to  produce  pain  or  vertigo.  It  is  always  a  safe  rule  in 
using  electricity  about  the  head  to  apply  the  current  after  an  increase 
to  one's  own  mastoids,  and  note  the  effect  before  applying  it  to  the  patient. 

Medicinal  agents  produce  little  result.  If  there  be  an  associated 
involvement  of  the  fifth  nerve,  or  even  without  this  if  there  l)e  redness 
of  the  throat,  salicylate  of  soda  maybe  used.  Alterative  tonics  such  as 
the  tincture  of  nux  vomica,  Fowler's  solution,  or  the  iron  preparations 
may  be  given. 

In  cases  where  the  degeneration  has  been  progressive  anrl  where 
there  is  no  evidence  of  restitution  of  function  either  to  volitional  effort 
or  to  the  electric  stimulus,  nerve  transplantation  has  been  tried  with 
fair  results.  (Taylor,  Clark.)  The  facial  is  cut  and  its  distal  end 
is  inserted  by  lateral  anastomosis  into  the  sheath  of  the  hypoglossal 
nerve.  Frazier  states  that,  as  a  rule,  the  sooner  the  operation  is 
done  the  better  the  results  to  be  expected.  When  we  believe  the 
nerve  to  be  destroyed,  as  after  operations  on  the  middle  ear,  etc., 
operation  should  be  performed  without  delay.  If  in  doubtful  cases 
at   the    expiration    of    six   months   there   is    not  the   slightest   sign   of 


DISEASES  OF  THE  SPINAL  COUD  891 

recovery,  operate  at  once.  As  to  operation  in  cases  of  long  standing 
{i.  e.,  two  up  to  twenty  years)  each  case  must  be  judged  from  the  stand- 
point of  the  electric  excitability  of  the  facial  muscles.  If  the  facial 
muscles  are  completely  atrophied  and  will  no  longer  respond  to  gal- 
vanic stimulation,  the  prospects  of  restoration  of  function  are  extremely 
doubtful.  For  a  full  discussion  of  this  subject  with  a  discussion  of  the 
technique  of  the  operation,  etc.,  see  Frazier,  Pennsylvania  Medical  Jour- 
nal, June,  1904,  vol.  vii..  No.  9.^ 

Root  Palsies. — Forcible  stretching  of  the  extremities,  especially  of 
the  arms  in  gymnastic  feats,  may  give  rise  to  a  degenerative  condition 
which  has  been  ascribed  to  lesions  of  the  nerve  roots.  The  symptoms 
do  not  differ  from  that  of  the  obstetrical  palsies  or  other  forms  of  plexus 
neuritis  except  in  the  persistence  of  the  symptoms.  When  the  eighth 
cervical  and  first  dorsal  roots  are  affected  there  may  be  dilatation  of 
the  pupil,  with  unilateral  sweating  of  the  face  on  the  affected  side 
(Klumpke's  paralysis).  The  treatment  is  the  same  as  that  given  above 
under  Neuritis.  The  prognosis  is  unfavorable,  when  the  roots  are  in- 
volved.    Operative  procedures  on  the  nerve  trunks  give  better  results. 


DISEASES  OF  THE  SPINAL  CORD. 

ACUTE  ANTERIOR  POLIOMYELITIS.     SPINAL  PARALYSIS  OF 

CHILDHOOD. 

The  peculiar  blood  supply  of  the  spinal  cord  whereby  the  gray  matter 
of  the  anterior  horns  receives  its  nutrition  almost  direct  from  the  anterior 
spinal  artery,  exposes  this  portion  of  the  spinal  cord  to  a  more  direct 
attack  from  infectious  or  toxic  material  in  the  circulating  blood  than 
occurs  in  the  other  columns  of  the  cord.  It  was  at  one  time  thought 
that  an  inflammatory  process  circumscribed  and  localized  to  a  limited 
area  was  always  localized  to  the  anterior  horns,  but  recent  observations 
have  shown  a  similar  process  aftecting  the  posterior  spinal  ganglia  in 
herpes  zoster. 

Etiology. — Several  epidemics  have  been  described.  The  disease  is 
probably  of  an  infectious  nature,  and  although  isolated  organisms  have 
been  found  in  the  cerebrospinal  fluid  no  distinct  causative  agent  has 
been  isolated.  \Yhile  as  a  rule  children  in  robust  health  are  affected,  it  is 
not  infrequent  in  a  large  number  of  cases  to  get  occasionally  a  direct 
antecedent  history  of  scarlet  fever,  measles,  or  gastroenteric  disturb- 
ances. Mothers  usually  blame  some  slight  injury,  but  traumatism  as  a 
factor  need  not  be  considered. 

Pathology. — The  lumbar  region  of  the  cord  is  most  frequently  affected, 
and  next  to  this  the  cervical  region.  The  pathological  process  varies 
from  a  simple  acute  congestion  to  an  active  acute  inflammation.    In  the 

1  See  also  Clark,  Taylor  and  Prout,  American  Journal  of  the  Medical  Sciences,  October,  1905,  for  a 
full  report  ou  this  class  of  cases. 


892 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Fig. 177 


later  stages  there  is  a  dilatation  of  the  arteries,  with  small  eapillary 
hemorrhages  and  a  heaping  up  of  small,  round  cells  about  the  vessels. 
Immediately  surrounding  the  central  focal  area,  where  the  nerve  cells 
are  imdergoingcoinj)]cte  degeneration,  there  is  a  perifocal  zone  of  con- 
gestion in  which  the  nerve  cells,  although  afiected,  arc  not  l)cvond  the 

stage  of  regeneration,  and  in  which  zone 
the  axis  cylinders  are  swollen.  This  zone 
may  extend  to  the  white  substance  of  the 
cord  in  the  innnediate  neighborhood  of 
the  anterior  horns.  In  cases  that  have  ex- 
isted for  a  long  time,  circumscribed  atrophy 
occurs,  with  decrease  in  size  of  the  anterior 
horns  and  a  partial  or  complete  absence  of 
the  functionating  ganglion  cells.  The  patho- 
logiciil  process  may  be  found  as  high  as  the 
medulla  in  rare  cases,  and  an  analogous, 
localized,  circmnscribed  inflammatory  pro- 
cess may  be  found  in  the  cerebrum  (en- 
cephalitis). 

Symptomatology.  —  A  perfectly  healthy 
child  or  one  convalescing  from  scarlet  fever 
or  other  acute  infection  may  awaken  in  the 
morning  with  a  paralysis  of  a  group  of 
muscles  or  an  entire  extremity.  More  frc- 
c|ucntly  the  disease  may  come  on  with 
fever,  ranging  from  102°  to  104°  F.,  antl  asso- 
ciated with  vomiting  and  anorexia.  In  rare 
cases  delirium  antl  convulsions  mark  the  on- 
set. The  fever  lasts  at  the  most  a  few  days 
and  may  be  so  slight  as  to  be  overlooked. 
Upon  examination  of  the  aflfected  part  the 
paralysis  is  found  to  be  flaccid,  with  a  com- 
plete absence  of  reflexes  in  the  distribution 
of  the  palsied  muscles.  This  rule  has  no 
exception.  The  commonest  location  of  the 
paralysis  is  in  the  peronei  group.  In  the 
focal  zone  of  the  inflammatory  process  the 
loss  of  function  will  remain  complete  and 
permanent.  In  the  perifocal  zone  where 
the  nerve  cells  have  been  altered,  but  where 
restitution  of  function  is  possible,  the  nuis- 
cles  will,  after  a  few  days,  begin  to  regain  function,  until  at  last 
where  a  whol(>  limb  was  at  first  affected  the  paralysis  may  persist 
in  only  a  single  muscle,  a  group  of  muscles,  or  the  flexors  alone. 
The  paralysis  is  always  of  an  atrophic,  degenerating  type  (Fig. 
177),  and  after  a  few  days  there  will  be  present  a  slowing  of  con- 
traction to  the  galvanic  current,  with  the  anodal-closing  contraction 
greater  than  the  cathodal;  in  unfavorable  cases  the  failure  to  react  to 


Poliomyelitis  aflfectiiig  the  left  arm 
and  right  leg. 


DISEASES  OF  TEE  SPINAL  CORD 


893 


increased  quantities  of  the  galvanic  current  progresses,  until  after  a  few 
months  there  is  absolutely  no  reaction.  ^Yhere  the  involvement  is  ex- 
tensive the  limb  fails  to  grow  and  remains  much  shorter  than  that  of 
the  opposite  side  (Fig.  178);  the  circulation  is  defective,  the  limb 
appearing  cyanosed  and  feeling  colder  than  the  normal  one.  Where 
opposing  muscles  to  those  paralyzed  retain  their  function  various  defor- 
mities may  result,  due  to  the  unopposed  contraction  of  the  normal 
muscles. 

Sensation  is  not  disturbed,  as  a  rule,  although  in  some  cases  the 
affected  muscles  may  be  tender  to  pressure.  The  sphincters  remain  intact. 
There  is  no  disturbance  of  mentality. 


Fig. 178 


Acute  anterior  poliomyelitis. 


Diagnosis.— In  the  acute  stage  this  disease  must  be  differentiated 
from  simple  congestive  conditions  of  the  cord,  neuritis,  rachitic  pseudo- 
paralvsis,  and  cerebral  palsies.  There  is  a  class  of  rare  cases,  two  of 
which  have  come  under  my  notice,  where,  after  an  apparently  causeless 
febrile  attack,  both  lower  limbs  have  suddenly  become  paralyzed  with 
loss  of  reflexes,  and  with  no  disturbance  of  sensation.  In  both  cases  the 
diagnosis  of  acute  anterior  poliomyelitis,  with  an  unfavorable  prognosis 
on  account  of  the  extent  of  the  paralysis,  was  given.    In  both  cases  after 


894  DISEASES  OF  THE  NERVOUS  SYSTEM 

a  week  tlic  paralysis  entirely  cleared  up.  I  know  of  no  way  of  making 
the  (litfenMitial  (iiao;nosis  in  these  eases  in  the  first  few  days,  but  if  in 
paralysis  of  this  extent  the  reactions  of  degeneration  are  not  typically 
developed  before  the  end  of  the  week  a  favorable  prognosis  shoidd  be 
given. 

The  pseudoparalysis  of  rickets  shows  the  following  clinical  picture: 
it  afl'eets  l)oth  extremities  and  is  at  times  associated  with  loss  of  reflexes, 
costal  beading  and  enlarged  epiphyses,  soft  muscles,  sweating  about 
the  head,  and  a  history  of  defective  feeding.  The  tenderness  of  scorbutic 
infants  with  pseudoparalysis  and  the  hemorrhagic  gums  will  always 
disaj)pear  by  dietetic  treatment.  From  the  cerebral  j)alsies  poliomyelitis 
can  be  difierentiated  by  the  flaccid  type  of  the  paralysis,  with  the  loss 
of  the  reflexes  and  the  absence  of  mental  symptoms.  Cerebral  spastic 
paraplegia,  which  is  most  often  mistaken  for  poliomyelitis,  aflFects  both 
lower  extremities;  the  reflexes  are  exaggerated;  the  muscles  are  spastic; 
there  are  no  reactions  of  degeneration;  the  condition  is  usiuilly  })resent 
from  birth  or  very  early  life,  and  there  is  a  history  of  tlifhcult  or  pro- 
longed labor  or  instrumental  delivery. 

The  absence  of  pain  and  of  tenderness  along  the  nerve  trunks,  and 
the  sudden  onset  will  difYerentiate  poliomyelitis  from  neuritis.  I  have 
found  the  greatest  difficulty  in  diagnosticating  those  cases  in  which  the 
paralysis  is  localized  to  a  single  muscle  or  muscle  grou}).  It  must  be 
remembered  that  the  only  reflexes  lost  are  those  under  the  motor  con- 
trol of  the  paralyzed  muscle.  In  a  child  of  four  years  of  age  who  began 
to  walk  on  the  heel  a  careful  examination  revealed  a  degenerating  par- 
alysis of  the  gastrocnemius  and  soleus  on  one  side  with  an  absence  of 
the  Achilles  reflex  on  that  side.  All  the  other  muscles  of  the  extremity 
and  all  the  other  reflexes  were  perfectly  normal. 

Prognosis. — The  prognosis  of  any  individual  case  should  not  be  made 
imtil  after  the  case  has  been  studied  for  a  ivw  weeks.  The  parents, 
however,  may  be  assured  that  the  resulting  paralysis  will  not  be  so 
extensive  as  that  at  the  onset.  The  more  limited  the  paralysis  the  better 
the  prognosis,  but  it  is  rare  except  in  the  most  limited  cases  for  a  com- 
plete return  of  function.  The  prognosis  is  better  when  the  paralysis 
affects  the  anterior  distribution  of  the  lower  extremity  than  when  it 
aft'ects  the  posterior,  and  more  return  of  function  may  be  expected. 
The  electric  examination  offers  the  best  method  of  determining  what 
muscles  will  regain  function. 

Treatment. — Absolute  rest  in  bed  for  at  least  two  or  three  weeks  is 
necessary  if  we  would  limit  the  process  to  its  ])rimary  destructive  zone 
and  give  the  cells  in  the  congestive  area  a  full  chance  to  regain  their 
function.  If  seen  early  in  the  febrile  stage  purgation  should  be  estab- 
lished, and  the  fever  reduced  by  a  simple  fever  mixture  and  free  sweating. 
While  drugs  have  no  curative  agency  the  salicylates  and  belladonna 
have  been  nuich  used.  Dry  or  wet  cups,  blisters,  and  leeches  have  been 
applied  over  the  lumbar  area  of  the  cord,  with  the  idea  of  relieving  the 
congestion,  but  I  have  never  seen  any  benefit  from  their  use.  After  the 
second  or  third  week,  during  which  time  the  nutrition  of  the  child  should 


DISEASES  OF  THE  SPINAL  CORD  895 

be  carefully  attended  to,  massage  and  passive  movements  should  be 
instituted.  While  it  is  advisable  to  secure  the  services  of  a  trained 
masseur,  inasmuch  as  it  will  be  often  necessary  and  advisable  to  keep  up 
this  treatment  at  least  a  year,  and  often  for  two  or  three  years,  where  the 
results  justify  continuance,  some  member  of  the  family  can  usually  be 
taught  the  underlying  principles  of  massage  so  as  to  produce  excellent 
results.  Except  in  the  very  well-to-do  it  has  been  my  rule  to  start  the 
treatment  with  a  trained  masseur  and  have  the  most  interested  and 
suitable  person  in  the  family  taught  the  necessary  manipulation,  and 
when  a  sufficient  degree  of  proficiency  is  acquired  to  continue  the  home 
treatment.  The  idea  in  the  treatment  is  to  have  a  well-nourished  muscle 
fibre  ready  to  take  up  the  function  as  soon  as  sufficient  nerve  power 
returns  to  the  affected  cells.  Care  must  be  used  to  prevent  deformities, 
and  is  best  obtained  by  passive  movements  given  with  massage.  While 
electricity  is  a  valuable  adjunct  in  keeping  the  muscles  in  good  condition, 
it  is  not  necessary  where  proper  massage  can  be  secured.  That  current 
should  be  used  which  secures  the  best  contraction  with  the  least  degree 
of  pain  and  discomfort  and  with  the  least  quantity  of  current.  Gymnastic 
exercises  if  well  regulated  are  valuable  after  the  above  treatment  is  well 
established.  Where  a  muscle  can  be  made  to  do  its  work  without  the 
assistance  of  apparatus  the  latter  should  not  be  employed.  Where  the 
paralysis,  however,  is  such  that  it  will  be  necessary  to  aid  in  securing 
rigidity  of  the  limb  to  overcome  a  marked  toe-drop  or  lateral  deviation 
of  the  foot,  a  simple,  light,  mechanical  appliance  will  be  indicated.  The 
more  simple  and  lighter  the  apparatus  the  better,  and  it  will  not  be 
necessary  in  all  cases  to  secure  either  the  services  of  an  orthopedist  or 
instrument  maker  to  secure  good  results.  An  elastic  band  applied  to 
the  shoe  and  to  a  garter  below  the  knee  in  such  a  way  as  to  take  up  the 
function  of  the  paralyzed  muscles  will  be  much  more  comfortable  and 
serviceable  than  a  complicated  metal  brace.  A  careful  study  of  the 
muscles  affected  and  of  the  mechanism  of  their  action  will  decide  in 
any  individual  case  whether  special  apparatus  will  be  necessary.  In 
any  event  the  greatest  care  in  supervision  on  the  part  of  both  the 
attending  physician  and  the  orthopedist  should  be  given  in  order  to 
cultivate  any  returning  power,  to  supply  any  increasing  deficiency,  or  to 
correct  any  developing  deformity.  In  cases  coming  under  observa- 
tion late  it  may  be  necessary  to  do  a  tenotoviy  in  order  to  secure  proper 
position  before  braces  can  be  applied.  In  selected  cases  excellent  results 
may  be  obtained  by  the  transplantation  of  tendons.  When  a  single 
muscle  or  allied  group  of  muscles  are  paralyzed  and  the  opposing  mus- 
cles, or  even  muscles  with  a  similar  function,  be  intact,  the  tendon  may 
be  divided  and  either  half  of  the  tendon  or  the  entire  tendon  implanted  on 
that  of  the  paralyzed  muscle.  Thus  one  of  the  tendons  of  the  common 
extensors  of  the  leg  or  even  half  of  this  may  be  attached  to  that  of  the 
anterior  tibial  when  this  is  paralyzed.  The  tendon  of  the  soleus  or  the 
split  tendon  of  the  tendo  Achillis  may  be  implanted  upon  the  perineus 
longus  et  brevis  to  restore  function  in  this  distribution.  In  the  upper 
leg  distribution  the  flexors  of  the  leg  may  be  transplanted  to  the  tendon 


896  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  the  (|ii;i(lri(c'|)s  with  j^ood  ivsults.  Similar  results  iiiny  !)(>  ohtaiuod 
in  the  ii})|K>r  r.\tr(Miiity.  The  traiisfcMViice  of  fuiution  of  flexor  imisclcs 
to  that  of  extensors  or  the  reverse  is  established  without  di(Heulty  and 
with  little  effort  and  training  on  the  part  of  the  patient.  Reeently 
Spiller  has  divided  the  nerves  in  a  longitudinal  direetion  and  implanted 
half  of  the  nerve  goin<:;  to  a  normal  functionating^  muscle  such  as  the 
common  extensors  of  the  le<i;  to  a  paralyzed  anterior  tibial.  It  is,  how- 
ever, too  soon  to  say  how  nuich  value  this  method  will  have.  Theoret- 
ically it  should  give  better  results  than  implantation. 


ACUTE  MYELITIS. 

Inflammatory  conditions  of  the  substance  of  the  spinal  cord,  INIyelitis, 
nuiy  be  divided  according  to  their  course  into  acute,  subacute,  and 
chronic  forms.  The  disease  may  be  limited  to  one  ])art  of  the  cord  or 
may  be  very  extensive. 

Etiology. — An  infection  of  the  spinal  tissues  during  or  following  one 
of  th(>  acute  infectious  fevers  is  the  most  common  cause  of  the  disease. 
It  has  been  known  to  follow  snudlpox,  typhoid  fever,  dysentery,  gonor- 
rhea, syphilis,  pneumonia,  influenza,  nudaria,  tonsillitis,  and  septic 
processes  such  as  cystitis,  pyelonephritis,  felons,  abscess  of  the  antrum, 
and  endocarditis.  It  results  not  infretjuently  by  extension  from  purulent 
conditions  of  the  meninges  in  epidemic  cerebrospinal  meningitis  and 
tuberculous  meningitis.  Localized  abscesses  in  the  bones  of  the  spine 
may  rupture  mio  the  spinal  canal,  with  the  production  of  a  transverse 
septic  myelitis.  Abscesses  without  the  spine  may  extend  along  the 
nerve  sheaths  and  produce  a  septic  infection  of  the  cord.  Traumatism 
from  stab  wounds,  bullet  wounds,  fracture  of  the  spine,  severe  over- 
exertion, and  si>ptic  infection  following  operations  on  the  s])ine  are 
recognized  causes.  Traumatism  without  rupture  of  the  overlying 
tissues  may  lead  to  multiple  punctate  hemorrhages,  which  in  turn  act 
as  irritants  and  lead  to  an  overgrowth  of  the  sup])<)rting  tissue  of  the  cord, 
presenting  the  manifestations  of  chronic  myelitis.  Extensive  hemor- 
rhage nuiy  occur,  with  destruction  of  cord  tissue.  I  have  reportxMl  a 
case  of  complete  destruction  of  almost  the  entire  dorsal  cord  from 
extensive  hemorrhagic  extravasation  following  severe  traction  on  the 
lower  (>xtremities  at  birth.  (See  article  on  Spinal  Hemorrhage.)  Sub- 
acute myelitis  is  a  common  condition  in  Pott's  disease,  due  to  pressure 
on  the  cord  from  the  thickened  meninges.  Alcohol,  lead,  mercury,  and 
phosphorus  have  been  blamed  for  disseminated  areas  of  myelitis. 
Undoubted  cases  develop  after  exposure  to  cold,  but  whether  the  cold 
acts  in  lowering  the  resistance  to  other  infections  or  acts  upon  some 
other  underlying  intoxication  has  not  been  determined.  While  the 
disease  may  occur  at  any  time  of  life  it  is  less  frequent  in  childhood 
than  in  adult  life. 

Pathology. — The  pathological  process  may  be  limited  to  one  or  two 
segments  of  the  cord,  may  extend  upward  or  downward  to  the  rest  of 


jyiSEASES  OF  THE  SPINAL  COBD  897 

the  cord,  or  may  be  a  diffused  process  with  disseminated  lesions  about 
the  vessels,  affecting  in  an  irregular  way  portions  of  or  the  entire  cord. 
The  membranous  covering  of  the  cord  may  be  reddened  and  injected  or 
may  appear  perfectly  normal.  On  section  of  the  affected  areas  the  cord 
is  of  a  soft,  creamy  consistence ;  the  gray  matter  cannot  be  differentiated 
from  the  white  and  the  cord  substance  is  either  of  a  red,  injected  color 
or,  if  the  disease  has  existed  for  some  time,  irregular  areas  of  yellow  may 
be  admixed  with  the  red.  If  the  process  be  localized,  secondary  degen- 
eration occurs  in  the  posterior  columns  and  the  direct  cerebellar  tract 
from  the  point  of  the  lesion  to  the  medulla,  and  degeneration  of  the 
crossed  pyramidal  motor  tracts  and  the  direct  pyramidal  tracts  below 
the  point  of  lesion  to  the  sacral  cord.  On  microscopic  examination  the 
bloodvessels  are  congested  throughout  the  entire  cross-section  of  the 
cord,  capillary  hemorrhages  are  present  in  the  gray  matter  and,  at  times, 
in  the  white  substance,  and  a  very  marked  and  extensive  accumulation 
of  small  round  cells  takes  place  about  the  vessels  or  infiltrates  the 
entire  area  of  section.  The  nerve  cells  of  the  anterior  horn  are  found 
in  all  stages  of  degeneration.  The  evidence  of  intense  destruction  of 
the  cord  tissue  is  shown  by  the  extensive  change  into  fat  when  the  sec- 
tions are  stained  by  osniic  acid.  The  cells  of  the  neuroglia  supporting 
tissue  undergo  active  proliferation  in  intense  cases,  and  supply  the  area 
of  the  destroyed  nervous  elements  when  healing  takes  place.  These 
cells  may  act  with  the  leukocytes  as  scavengers  for  the  removal  of  the 
destroyed  nervous  tissue.  In  the  disseminated  form  small  focal  areas 
of  perivascular  round-cell  accumulation  will  be  found  scattered  here 
and  there  throughout  the  cord.  In  such  cases  the  process  is  more  likely 
to  run  a  subacute  or  chronic  course,  and  is  more  apt  to  be  followed  by 
a  sclerosis  of  the  cord  tissue  with  less  active  destruction  of  the  cord 
elements  than  in  the  acute  localized  form.  The  intoxications,  as  a  rule, 
lead  to  a  slow  overgrowth  of  the  neurogliar  tissue,  without  acute  mani- 
festations. 

Symptomatology. — In  the  acute  form,  and  especially  that  form  due 
to  septic  infections,  the  disease  develops  rather  suddenly,  with  fever 
varying  from  100°  to  104°  F.  Pain  in  the  back  may  be  slight  or  very 
intense,  and  referred  to  those  areas  supplied  by  the  portions  of  the  cord 
affected.  There  is  marked  tenderness  to  pressure  on  the  back.  Hot 
applications  are  poorly  borne  over  the  affected  area.  Evidence  of  dis- 
turbance of  function  of  the  cord  are  present  very  early,  and  depend 
upon  the  portion  of  the  cord  affected.  If  the  process  be  localized,  as  it 
most  frequently  is,  to  the  dorsal  part  of  the  cord,  all  motor  impulses 
coming  from  the  brain  are  interrupted  at  this  point,  and  a  paralysis 
of  the  legs,  bladder,  and  rectum,  and,  if  the  lesion  be  sufficiently 
high,  of  the  abdominal  and  spinal  muscles  results.  All  the  sensory 
impulses  (pain,  touch,  temperature,  and  muscular  sense)  are  interrupted 
at  this  point  in  their  course  from  the  periphery  to  the  brain  and  are  not 
perceived.  In  other  words,  there  is  a  complete  loss  of  sensation  in  the 
lower  extremities  and  of  the  trunk  up  to  the  upper  level  of  the  lesion. 
At  this  level  the  skin  is  hyperesthetic,  due  to  the  irritation  of  the  nerve 
57 


898  DISEASES  OF  THE  NERVOUS  SYSTEM 

fibres  ill  tlir  {Kiipheral  zone  of  the  inflaniinatory  process.  If  the  process 
is  limited  to  the  dorsal  cord,  and  the  hiinhar  eiihiriijeineiit  siipplyin<ij 
nutrition  and  reflex  function  to  tlie  lower  extremity  remains  intact,  the 
reflexes  of  the  legs  will  be  increasetl,  there  will  be  ankle  clonus,  and 
upon  irritation  of  the  sole  of  the  foot  the  toes  will  be  extended  instead 
of  becoming  flexed.  (See  p.  S61.)  The  disturbance  of  tiie  bladder 
from  a  lesion  in  this  area  will  be  a  retention  of  urine  followed  by  over- 
flow— the  incontinence  of  retention.  This  is  due  to  the  contraction  of 
the  sphincter,  which  retains  its  normal  motor  power,  increased  by  the 
increase  of  reflex  excitability,  the  retention  of  the  reflexes,  and  the  loss 
of  volitional  control  from  the  interruption  in  the  dorsal  region.  In 
lower  lesions  affecting  the  lumbar  and  sacral  cord  the  sphincter  becomes 
paralyzed,  the  reflexes  are  lost,  and  there  is  incontinence  of  urine  without 
retention.  The  same  is  true  for  the  rectum.  In  low  lesions  afl'ecting 
the  lumbar  cord  the  paralysis  is  confined  to  the  legs,  and  is  of  a  flaccid 
type,  with  loss  of  reflexes,  atrophic  degenerations  of  the  nmscles,  and  loss 
of  sensation  to  the  upper  limit  of  the  lesion,  which  in  some  cases  may  be 
at  the  hip  or  in  others  as  high  as  the  upper  limit  of  the  inflammatory 
processes  in  the  dorsal  cord.  In  low  lesions  the  loss  of  trophic  influence 
due  to  the  destruction  of  the  anterior-horn  cells  commonly  results  in 
extensive  bed-sores,  which  add  a  new  source  of  infection  and  become 
a  most  serious  complication. 

If  the  process  be  localized  to  the  cervical  lesion  of  the  cord,  as  is  not 
infreiiuently  the  case  in  Pott's  disease,  there  is  a  paralysis  of  the  arms, 
flaccid  in  typ(\  with  loss  of  arm  reflexes,  due  to  a  (listurl)ance  of  the 
reflex  mechanism  localized  to  the  cervical  area.  The  biceps  jerk  and 
triceps  jerk  are  absent.  The  paralysis  in  the  arms  is  a  degenerative 
atrophic  type.  The  paralysis  of  the  lower  extremity,  the  involvement 
of  the  bladder  and  rectum,  and  the  retention  of  the  reflexes  are  the  same 
as  that  of  the  doi-sal  lesions  first  described.  In  cervical  lesions  the  entire 
body  is  anesthetic  up  to  the  neck. 

In  the  severe  cases  with  bed-sores  and  cystitis  the  temperature  range 
is  irregular,  the  tongue  is  dry  and  coated,  the  patient  becomes  delirious, 
and  death  ensues  either  from  uremic  or  septic  intoxication.  In 
the  less  severe  cases  the  inflammatory  symptoms  subside  after  a  few 
weeks,  and  the  patient  either  may  remain  completely  paralyzed,  with  the 
development  of  contractures  in  parts  below  the  lesion,  or  there  may  be 
partial  or  complete  recovery  of  function,  depending  upon  the  extent  to 
which  the  spinal  tissues  were  destroyed.  Recovery  of  function  may 
take  place  in  some  of  the  muscles  of  an  affected  extremity,  while  others 
remain  partially  or  completely  paralyzed  and  atrophic.  In  lesions 
above  the  lumbar  enlargement  it  is  the  exception  for  recovery  to  take 
place  without  some  stift'ness  of  the  gait  and  loss  of  power. 

In  the  subacute  and  mild  acute  cases  sensation  and  motion  may  be 
only  partially  interfered  with.  Occasionally  I  have  seen  in  cases  asso- 
ciated with  complete  or  only  partial  loss  of  power  a  hyperesthesia  of  the 
skin,  followed  only  late  or  not  at  all  by  anesthesia.  In  the  diffuse  dis- 
seminated form  all  four  extremities  may  be  mildly  affected  with  partial 


DISEASES  OF  THE  SPINAL  CORD 


899 


loss  of  power  and  sensation,  or  the  clinical  picture  may  be  the  same  as 
that  above  described. 

Diagnosis. — In  the  case  above  referred  to  in  the  etiology  of  extensive 
hemorrhage  due  to  traction  on  the  extremities  an  interesting  case  for 
diagnosis  was  presented.  The  attending  obstetrician  was  accused  of 
causing  the  paralysis  and  suit  was  threatened  for  malpractice.  Imme- 
diately after  birth  it  was  noticed  that  there  was  complete  paralysis  of 
the  lower  extremities.  When  the  child  was  stripped  a  flaccid,  protuberant 
condition  of  the  abdomen  was  presented.    The  distended  bladder  could 


Fig. 179 


Transverse  myelitis.    Paralysis  of  thorax,  abdomen,  and  legs. 


be  seen  as  a  spherical  tumor  rising  almost  as  high  as  the  umbilicus. 
Sensation  was  lost  in  the  lower  extremities  and  the  trunk  as  high  as  the 
fourth  dorsal  vertebra.  The  reflexes  of  the  lower  extremity  were  present 
and  prompt.  There  was  no  wasting  of  the  lower  extremities,  nor  were 
there  reactions  of  regeneration  to  the  electric  current.  This  fact 
together  with  the  incontinence  or  retention  of  urine  led  us  to  assume 
that  the  lumbar  enlargement  of  the  cord  was  normal,  and  that  there 
existed  a  complete  destructive  lesion  in  the  dorsal  cord.  The  body 
above  the  waist  was  perfectly  normal.     A  diagnosis  of  hemorrhage 


cjoo  DISEASES  OF  THE  NERVOUS  SYSTEM 

into  the  cord  at  birth  or  shortly  before  birth  ufter  tlie  spinal  eord  liad 
been  fully  developed  was  made.  This  diagnosis  was  fully  eon  firmed  by 
autopsy,  ^^'hieh  showefl  an  extensive  hemorrhagic  extravasation  destroy- 
ing a  large  portion  of  the  dorsal  eord.     (See  Fig.  179.) 

Prognosis. — In  severe  eases  the  necessity  of  evacuating  the  bladder  by 
means  of  a  catheter  exposes  the  patient  to  such  risks  from  ext(>rnal 
infection,  due  to  the  lowered  resistance,  that  it  is  always  an  important 
factor  in  leading  us  to  make  a  guarded  prognosis.  The  same  may  be 
said  of  bed-sores;  and  when  with  extensive  bed-sores  the  temperature 
becomes  high  and  irregular,  in  spite  of  local  treatment,  a  fatal  outcome 
may  be  expected.  In  early  infancy  the  prognosis  is  more  unfavorable 
than  in  later  life.  The  prognosis  as  far  as  recovery  of  function  is  con- 
cerned depends  on  the  extent  of  the  primary  loss  of  function  and  the 
course  of  the  disease.  If  the  inflanunatory  lesion  persists  for  several 
weeks  with  some  fever,  and  the  restitution  of  function  during  this  time 
does  not  become  evident,  the  resulting  paralysis  will  in  all  jjrobability 
be  persistent.  If  the  inflammatory  symptoms  rapidly  subside,  even 
though  the  paralysis  at  first  nuiy  be  complete,  fair  restitution  of  function 
mav  take  {)lace.  The  prognosis  must  in  all  cases  be  a  matter  of  study 
of  the  individual  case. 

Treatment. — The  sooner  the  patient  is  placed  at  absolute  rest  in  l)ed 
the  better.  A  careful  search  should  then  be  made  for  any  underlying 
sepsis  or  intoxication,  and  this  as  far  as  possible  removed.  If  there  be 
evidence  of  syphilis  a  course  of  mercurials  or  of  the  mixed  treatment 
shoukl  be  inunediately  begun  if  this  is  considered  to  be  the  cause  of 
the  disease.  It  is  better  in  all  severe  cases  to  employ  from  the  beginning 
a  water  or  air  mattress.  The  air  mattress  should  be  perfectly  smooth, 
and  the  air  free  in  the  mattress  so  that  the  surface  of  the  body  will  rest 
in  uniform  pressure.  The  air  mattress  used  in  camping,  divided  into 
compartments  and  with  an  irregular  flat  surface,  should  not  be  employed. 
A  proper  air  mattress,  with  scrupulous  cleanliness  and  oversight  that 
the  bed-clothing  should  be  kept  dry  and  evenly  spread  without  wrinkles, 
is  the  best  method  of  preventing  bed-sores.  In  r(>tention  of  urine  where 
catheterization  is  necessary,  the  greatest  care  and  cleanliness  should  be 
observed;  in  incontinence  of  urine  a  bed  urinal  may  be  employed,  or 
wads  of  antiseptic  cotton  fretpiently  changed  may  answer  the  same 
purpose.  Careful  attention  to  the  above  details  by  a  conscientious 
trained  nui'se  is  of  the  utmost  importance  in  the  treatment.  Frequent 
washing  of  the  back  with  an  astringent  solution,  such  as  alum  and 
alcohol,  will  assist  in  keeping  the  skin  in  good  condition.  Reddened, 
areas  of  the  skin,  the  forerunner  of  bed-sores,  should  be  carefully  re- 
moved from  pressure  by  the  air  ring  or  rings  of  cotton  carefully  applied. 
The  skin  should  be  kept  clean  and  the  red  areas  painted  with  nitrate 
of  silver  0.(i5  gm.  (10  gr.)  to  1.3  gm.  (?()  gr.)  to  30  c.c.  (one  ounce)  to 
harden  the  skin.  If  bed-sores  have  formed,  pressure  should  be  likewise 
relieved,  the  ulcerated  surface  frequently  cleansed  with  hydrogen 
peroxide,  followed  l)y  a  weak  carbolic  or  other  antiseptic  solution,  and 
a  constant  wet  dressing  applied.     Where  any  tendency  to  healing  is 


DISEASES  OF  THE  SPINAL  CORD  901 

shown,  the  edges  may  be  touched  up  with  strong  solutions  of  nitrate  of 
silver  and  ointments  applied.     I  have  found  the  use  of  a  prescription  of 

Jfc— Cocaine 0.06  gm.  (gr.  j). 

Menthol 0.30  gm.  (gr.  v). 

Petrolatum      .       .       .       .       .       .       ...       .       .  30.00  gm.  (Sj). 

M.  et  ft.  unguentum. 

useful.  The  general  nutrition  of  the  patient  should  be  carefully  attended 
to  and  a  good  nutritious  diet  employed. 

Local  applications  to  the  spine  do  little  good.  I^ong  ice-bags  or  in 
other  cases  hot  applications  relieve  the  pain.  The  spasmodic  contrac- 
tion of  the  legs  in  dorsal  lesions  may  be  relieved  by  hot  applications 
and  the  use  of  the  bromides  internally.  Internal  medication  during  the 
acute  process,  except  in  the  cases  due  to  syphilis,  gives  little  result.  The 
salicylates  are  frequently  used  in  the  infectious  cases  and  may  do  some 
good. 

During  convalescence  from  the  acute  process  the  patient  should  be 
carefully  guarded  from  attempts  at  walking  or  other  use  of  the  muscles. 
I  have  known  cases  otherwise  doing  well  to  develop  serious  symptoms 
from  the  jar  of  falling  or  in  riding,  as  in  one  case  where  it  was  necessary 
to  remove  the  patient  in  a  carriage  over  city  streets  several  weeks  after 
convalescence  had  begun.  The  primary  return  of  power  may  be  ex- 
pected to  be  more  or  less  interfered  with  by  the  contraction  of  the 
inflammatory  tissue  and  the  secondary  degeneration  above  described. 
To  lessen  this  secondary  rigidity  and  to  prevent  contractures  are  the 
main  objects  of  treatment  during  convalescence.  No  active  motion 
should  be  permitted  for  at  least  a  month.  Passive  movements  should 
then  be  begun  and  gentle  massage  employed.  Ordinary  massage,  as 
a  rule,  unless  carefully  performed  by  a  skilled  operator,  leads  to  spas- 
modic contractions  of  the  affected  muscles.  Passive  movements  carried 
out  with  the  patient  in  a  hot  bath  and  gentle  massage  under  hot  water 
give  the  best  results.  In  using  the  hot  bath  for  this  purpose  care  should 
be  taken  to  protect  the  patient  from  cold.  When  the  inflammatory 
process  affects  the  lumbar  or  cervical  enlargement  and  there  is  wasting 
of  the  muscles,  massage,  electricity,  and  the  use  of  mechanical  appli- 
ances as  directed  for  the  paralytic  conditions  of  poliomyelitis  should  be 
employed. 

It  may  be  necessary  to  overcome  the  contractures  by  tenotomy  of 
the  hamstring  or  Achilles  tendons.  When  the  angle  of  contracture  is 
marked,  gradual  straightening  of  the  extremity  should  be  employed  in 
preference  to  the  rapid  method  in  vogue  among  surgeons.  In  a  case  of 
mine,  where  the  latter  method  was  employed,  a  degenerative  paralysis 
of  the  legs  below  the  knee  resulted  from  a  too  forcible  stretching  of  the 
perineal  nerves.  Section  of  the  Achilles  tendon  relieves  the  spasm  of 
the  calf  muscles  and  is  beneficial  in  controlling  a  persistent  ankle  clonus 
— a  very  troublesome  condition  which  seriously  interferes  with  the  gait 
of  the  patient.  Transplantation  of  tendons  for  the  paralyzed  and 
atrophic  muscles  may  be  employed  as  in  poliomyelitis. 


902  DISEASES  OF  THE  NEE  VO  US  SYSTEM 


POTT'S  DISEASE. 

Potts  Disease  is  of  importance  in  connection  witli  diseases  of  the 
spinal  cord,  because  of  the  various  mechanical,  inflammatory,  and  de- 
generative changes  it  produces. 

While  Pott's  disease  may  occur  at  any  time  of  life  it  is  much  more 
common  in  childhood.  The  disease  is  a  tuberculous  process  affecting 
the  bodies  of  the  vertebnv  and  occurs  in  children  of  a  tuberculous  or 
scrofulous  diathesis.  Traumatism  is  an  important  determining  factor, 
and  need  only  be  slight.  This  disease  is  here  considered  with  reference 
to  the  changes  it  produces  in  the  spinal  cord. 

Pathology. — The  disease  of  the  bodies  of  the  vertebrne  (one  or  more 
vertebnv  may  be  involved)  results  in  a  displacement  of  the  bodies 
of  the  vertebrae  one  upon  the  other,  with  a  resulting  deformity  of 
the  spine.  The  extent  of  the  deformity  depends  to  a  great  extent 
upon  the  part  of  the  spine  affected  and  the  age  of  the  patient.  In  grow- 
ing children,  and  before  the  bones  of  the  spine  have  set  for  their  adult 
function,  the  deformity  is  much  more  common  and  much  more  exten- 
sive than  it  is  in  adult  life.  When  the  process  is  localized  to  one  or  two 
vertebrie,  a  slight  angular  kyphosis  is  presented.  In  lesions  of  the 
cervical  region  it  may  be  necessary  to  carefully  search  for  any  deformity. 
From  a  slight  angular  kyphosis  all  grades  are  seen — to  extensive  arching 
and  irregular  deformity.  The  result  of  the  deformity  is  to  produce  a 
narrowing  of  the  spinal  canal.  If  the  narrowing  be  marked  it  may  lead 
to  pressure  on  the  spinal  cord,  which  becomes  flattened  out  and  dis- 
eased at  this  point.  This  narrowing  of  the  spinal  canal  is  in  some  cases 
so  marked  as  to  leave  only  a  snuill  passage  for  the  cord.  The  cord  may 
be  only  one-fourth  of  its  normal  diameter.  The  compression  of  the 
cord  and  the  resulting  symptoms  are  accentuated  by  the  development 
of  a  pathological  exudate  on  the  outer  surface  of  the  dura  mater  (exter- 
nal pachymeningitis).  The  thickening  of  the  meninges  is  due  to  the 
irritative  bone  process.  In  cases  with  little  deformity  this  may  be  so 
marked  and  extensive  avS  to  cause  marked  compression  of  the  spinal 
cord  with  little  narrowing  of  the  spinal  canal.     (See  Figs.  181,  182.) 

In  rare  causes  a  localized  abscess  may  form  in  the  bone  and  suddenly 
rupture  into  the  canal,  with  complete  local  destruction  of  the  spinal 
cord.  In  a  case  with  no  deformity,  in  which  the  l)one  lesion  was  not 
suspected,  the  symptoms  developed  suddenly,  with  evidence  of  com- 
plete destruction  of  the  cord  in  the  upper  dorsal  area.  A  diagnosis  of 
hemorrhage  into  the  cord  was  made.  At  the  autopsy  an  abscess  cavity 
in  the  body  of  one  of  the  vertebra:'  was  found  to  have  ruptured  into  the 
spinal  cord. 

While  the  bone  process  is  usually  localized  to  a  single  area  of  the 
spine,  double  lesions  are  not  infrequently  met  with. 

Lesionft  of  the  Spinal  Cord. — The  extensive  inflammatory  exudate  of 
the  dura  is  shown  at  autopsy  by  strong  adhesions  at  the  point  of  disease. 
The  cord  at  this  point  may  be  softened,  edematous,  or,  in  slowly  pro- 


DISEASES  OF  THE  SPINAL  CORD 


903 


gressive  cases  of  long  duration,  may  be  of  normal  consistence  but  flat- 
tened. Above  and  below  the  point  of  pressure  secondary  degeneration 
of  the  cord  is  marked.  On  microscopic  examination  the  changes  vary 
from  a  slight  edema  with  congestion  in  the  mild  cases  to  extensive 
destruction  of  cord  tissue,  capillary  hemorrhage,  and  round-cell  infil- 
tration about  the  vessels.     An  acute,  terminal  tuberculous  inflamma- 


FiG.  180 


Fig. 181 


Cervical  Pott's  disease. 


Dorsolumbar  Pott's  disease. 


tion  of  the  membranes  of  the  cord  (the  pia  mater  and  arachnoid)  or  a 
localized  chronic  plastic  exudate  on  the  inner  surface  of  the  dura  may 
be  present. 

Symptomatology. — In  this  disease  the  symptoms  referable  to  the  spine 
develop  insidiously.  They  may  occur  immediately  after  a  traumatism, 
or  a  period  of  weeks  or  even  months  elapse.  The  spine  becomes  more 
or  less  rigid,  there  is  a  certain  stiffness  to  the  body  movements,  and 


904  DISEASES  OF  THE  NER  VO  US  S  YSTEM 

l()c;ili/('(l  pain  and  tenderness  are  presented.  Subjective  symptoms 
niav  l)e,  however,  entirely  absent,  and  the  very  <,n-a(hial  develojjnient 
of  the  spastic  paralysis  of  the  lower  extremities  may  he  the  first  evidence 
of  the  disease  process.  Inasmuch  as  the  caries  affects  the  dorsal  and 
cervical  rcfjions  in  most  cases,  the  paralysis  is  spastic  in  type,  with  an 
increase  of  the  reflexes,  ankle  clonus,  and  the  Bahinski  reflex. 

In  the  earlv  stages  one  leg  may  be  more  paralyzed  than  the  other. 
There  mav  be  no  disturbance  of  sensation  in  the  mild  cases,  or  there 
luav  b(>  complete  anesthesia  in  the  severe  cases  up  to  the  level  of  the 
lesion.  In  such  cases  the  bladdtT  and  rectal  functions  will  be  disturbed 
as  in  cases  of  myelitis.  The  inflammatory  process  in  the  dura  mater 
mav  j)roduce  irritation  of  the  nerve  roots  and  cause  intense  pain  in 
their  distribution.  Slight  irritation  of  the  roots  gives  rise  to  increased 
sensitiveness  to  touch  and  pain  impressions.  The  di.stribution  of  the 
pressure  on  the  spinal  cord  may  be  such  Jis  to  cause  a  loss  of  some 
forms  of  sensation  with  the  retention  of  others.  Thus  sensation  for 
pain  and  temperature  may  be  lost,  and  sensation  for  touch  retained 
and  normal.  If  the  cervical  part  of  the  spinal  cord  is  affected  all  four 
extremities  are  involved;  a  flaccid  paralysis  with  wasting  and  degenera- 
tion of  the  muscles  in  the  arms,  and  a  spastic  paralysis  in  the  legs.  In 
cervical  lesions  above  the  cervical  enlargement  the  paralysis  of  all  four 
extremities  may  be  spastic  in  type,  and  the  sensory  disturbance  affect 
the  whole  body  with  the  exception  of  the  head.  Bed-sores  are  some- 
times present.  In  pressure  lesions  affecting  the  lumbar  enlargement 
of  the  cord,  the  paralysis  of  the  lower  extremities  is  flaccid  in  type,  with 
loss  of  the  reflexes,  wasting  of  the  muscles,  bed-sores,  and  incontinence 
of  urine. 

Diagnosis. — The  diagnosis  of  Pott's  disease  in  children  is  not  a  diffi- 
cult matter  if  the  rules  for  diagnosis  of  nervous  conditions  of  childhood, 
laid  down  at  the  beginning  of  the  chapter,  are  observed.  Even  in  the 
verv  earlv  cases,  where  the  disturbance  of  the  motor  function  is  very 
slight,  an  examination  of  the  naked  child  will  show  the  limitation  of  the 
movement  of  the  spine  and  any  slight  deformity  when  the  child  bends 
the  l)odv.  Percussion  over  the  spine  with  the  index  finger  placed  over 
each  successive  vertebra  and  a  fairly  strong  percussion  tap  made  on 
this  finger  will  reveal  a  sensitive  area  at  the  j)oint  (if  disease.  In  advanced 
cases  there  is  usually  no  difficulty  on  account  of  the  very  evident  deform- 
ity. I  have  seen,  however,  in  an  adult  an  aneurysm  produce  erosion 
of  the  vertel)ra^  and  deformity  of  the  spine  sufficiently  marketl  to  be 
mistaken  for  Pott's  disease. 

Prognosis. — Prognosis  in  any  individual  case  will  depend  upon  how 
far  the  disease  of  the  bone  can  be  controlled.  In  mild  cases  if  the  proper 
treatment  can  be  carried  out  the  prognosis  for  return  of  function  in  the 
course  of  a  few  months  is  good.  Prognosis  for  the  return  of  function 
of  the  cord,  even  in  those  cases  where  there  is  marked  pressure  and 
flattening  out  of  the  cord,  is  not  altogether  unfavoralile.  Even  a  very 
thin,  narrow  band  of  spinal  cord  has  been  found  to  transmit  impulses 
which  in  cases  flue  to   other  lesions  would    not  be  expected.     This  is 


DISEASES  OF  THE  SPINAL  CORD  905 

due  probably  to  the  gradual  development  of  the  pressure  and  the 
accommodation  of  the  nervous  tissues  to  the  new  conditions. 

Treatment. — The  treatment  of  the  spinal  lesions  is  the  removal  of 
the  bone  disease.  Whether  this  be  obtained  by  rest  in  bed,  with  exten- 
sion and  nutritive  measures,  or  whether  surgical  means  are  employed, 
the  result  should  be  obtained  as  soon  as  possible  in  order  to  relieve  the 
pressure  on  the  cord.  The  spine  should  be  placed  absolutely  at  rest 
either  by  the  head  extension  above  referred  to  or  a  plaster-of-Paris 
jacket.  Fresh-air  treatment  with  overfeeding  by  milk  and  eggs — prefer- 
ably carried  out,  especially  during  the  summer  months,  at  some  sea- 
side resort,  where  the  bed  of  the  patient  with  its  extension  apparatus 
intact  can  be  wheeled  to  a  porch  in  the  fresh  air  and  sunshine  secured 
most  of  the  day — will  give  the  best  results.  Direct  exposure  of  the  back 
and  the  trunk  to  the  sun  has  given  valuable  results.  This  may  be  also 
carried  out  with  a  little  extra  trouble  at  home.  It  should  be  remembered, 
as  far  as  active  surgical  procedures  for  the  relief  of  the  bone  condition  or 
the  removal  of  the  exudate  about  the  spinal  cord  is  concerned,  that  child- 
ren react  poorly  to  operative  insults  to  the  nervous  system,  and  there  is 
always  the  possibility  of  producing  a  blood  infection  with  miliary  tuber- 
culosis by  even  slight  operative  procedures.  The  same  is  true  of  forcible 
extension  of  the  spine,  with  the  idea  of  forcing  the  bones  back  to  a 
straight  position  at  a  single  sitting.  Much  better  and  safer  results  are 
secured  by  more  conservative  measures. 

The  treatment  of  the  paralysis,  the  wasting,  contractures,  and  bed- 
sores is  the  same  as  that  suggested  for  Myelitis  and  Poliomyelitis. 

Medicinal  treatment  apart  from  the  alterative  tonics  is  of  little  value. 
When  there  is  no  lung  involvement  the  iodides  and  mercurials  have 
been  given  with  reputed  benefit. 


TUMORS  WITHIN  THE  SPINAL  CANAL. 

Tumors  of  the  spinal  cord  or  its  meninges,  while  rare  at  any  time  of 
life,  are  especially  rare  in  childhood.  Of  the  fifty  cases  of  tumor  of  the 
spine  collected  by  Mills  and  Lloyd,  14  per  cent,  were  under  twenty  years 
of  age,  four  before  the  age  of  ten,  and  three  between  ten  and  twenty. 
The  most  common  forms  of  cord  tumors  in  childhood  are  syphilitic  and 
tuberculous.  Gliomata  and  cystic  tumors  sometimes  occur.  The 
tuberculous  tumors  may  be  multiple  and  can  occur  in  the  same  case 
with  a  Pott's  disease.  In  a  boy  of  eight  who  died  from  a  miliary  tuber- 
culosis following  an  operation  for  caries  of  the  foot,  two  tumors  tuber- 
culous in  nature  in  the  sacral  portion  of  the  spinal  cord  and  cauda  equina 
were  found.  In  another  case  a  tuberculous  tumor  of  the  meninges, 
which  completely  infiltrated  and  destroyed  the  spinal  cord  in  the  dorsal 
area,  was  associated  with  a  tumor  the  size  of  an  olive  in  the  cauda  equina. 
Tumors  either  of  the  cord  or  of  the  meninges  cause  destruction  of  the 
cord  by  slow  invasion  or  by  pressure.  Above  and  below  this  point 
secondary  degeneration  occurs. 


906  DISEASES  OF  THE  NERVOUS  SYSTEM 

Symptomatology. — The  symptoms  of  tumors  witliin  tlic  spine  dovclop 
gradually  ami  are  pr()<i;ressive.  Tvunors  l)e<^Miuiin<,'  in  the  meninges 
produee  intense  pain  by  involvement  of  the  posterior  roots,  and  the  pain 
is  referred  to  the  distribution  of  the  roots  involvetl.  The  pain  in  tumors 
of  the  lumbar  enlarfi^ement  is  referred  to  the  le()js,  in  the  dorsal  enlarjjje- 
ment  to  the  ehest,  and  in  tlie  cervical  enlar^^ement  to  the  arms.  There 
may  be  some  tenderness  on  percussion  at  the  seat  of  the  tumor.  Involve- 
ment of  the  anterior  roots  by  the  tumor  process  produces  nmscular  jerk- 
ings  very  early,  followed  V)y  paralysis  and  muscular  atrophy.  When  the 
tmnor  begins  within  the  spinal  cord  the  symptoms  of  root  irritation, 
lancinating  pains,  atrophy,  etc.,  develop  late.  The  other  symptoms  of 
tumors  of  the  spinal  cord  are  due  either  to  compression  or  to  destruction 
of  the  cord  tissue,  and  in  this  respect  will  not  differ  in  results  from  those 
of  a  local  myelitis  at  this  same  area.  These  symptoms  will,  however, 
develop  very  gradually  and  will  not  be  associated  with  the  symptoms 
of  inflammation  of  that  process.  When  the  tumor  begins  on  one  side 
of  the  cord  the  symptoms  at  first  are  referred  only  to  this  distribution. 
Thus,  given  a  tumor  above  the  cervical  enlargement,  there  will  at  first 
be  a  constricting  pain  about  the  neck,  a  dull  pain  over  the  cervical 
processes,  and  a  progressive  loss  of  |)ower  of  the  arm  and  leg  of  the 
same  side  as  the  tumor.  The  paralysis  of  the  arm  and  leg  will  be  spastic 
in  type  or  at  least  associated  with  increase  of  the  reflexes,  with  ankle 
clonus  and  the  Babinski  reflex.  When  only  one-half  of  the  cord  is 
involv(>d  the  sensory  fibres  of  touch,  pain,  and  temperature  from  the 
opposite  side  of  the  body,  which  have  crossed  over  as  soon  as  they  have 
entered  the  cord,  will  be  obstructed  at  this  point,  and  there  will  be  an 
anesthesia  to  all  these  forms  of  sensation  on  the  side  opposite  to  that 
paralyzed  up  to  the  point  of  lesion.  The  sensory  fibres  on  the  same  side 
as  the  tumor,  having  crossed  over  upon  entering  the  cord,  find  an  miol)- 
structed  j)ath  through  the  unaffected  half  of  the  cord  to  the  brain,  and 
sensation  on  this  side  will  be  normal.  As  the  disease  progresses  and 
more  than  half  of  the  cord  is  involved  the  loss  of  power  gradually  affects 
the  arm  and  leg  of  the  opposite  side,  and  sensation  over  the  entire  body 
is  aftect(Ml  to  complete  loss.  When  this  stage  is  reached  there  is  incon- 
tinence of  urine  and  feces  and  a  tendency  to  contractures  in  the  ]:)aralyzed 
muscles.  When  the  tumor  aftects  the  cervical  enlargement  flaccitl 
paralysis  of  the  arm  or  arms  will  be  found,  as.sociatefl  with  wasting  as 
soon  as  the  destruction  of  tissue  in  this  area  is  complete.  The  paralysis 
below  this  ])oint  will  remain  spastic  as  before.  When  the  lumbar 
enlargement  is  involved  the  paralysis  is  confined  to  the  lower  extremity, 
and  becomes  flaccid  and  wasting  in  type  when  the  destruction  of  the 
cord  tissues  is  completed.  There  will  be  incontinence  of  urine  and 
feces.  Sensation  may  at  first  be  lost  here  only  in  the  opposite  leg,  Init 
later  may  attect  l)()th  legs. 

Diagnosis. — From  Pott's  disease  tumors  can  usually  be  differentiated 
by  the  deformity,  the  predominance  of  bone  pain,  and  the  evidence  of 
bone  disease,  and  in  cases  without  deformity  by  an  .r-ray  examination. 
The  loss  of  power  in  both  conditions  comes  on  slowly,  but  there  is  not 


DISEASES  OF  THE  SPINAL  CORD  907 

such  evidence  of  complete  loss  of  power  in  caries  as  in  tumor.  Tumors, 
as  a  rule,  run  a  more  rapid  course. 

From  myelitis  a  tumor  can  usually  be  differentiated  by  the  slowness 
of  onset  of  the  latter,  with  absence  of  inflammatory  symptoms  and  the 
predominance  of  pain;  whereas,  in  myelitis  the  onset  is  rapid,  there  is 
less  pain,  and  rapid  destruction  of  function.  Restitution  of  function 
in  myelitis  after  the  acute  symptoms  have  subsided  is  an  important 
factor  in  diagnosis.  Tumor  can  be  differentiated  from  neuritis  or 
multiple  neuritis  by  the  more  rapid  onset  of  the  latter,  the  tenderness 
over  the  nerves  and  muscles,  and  the  loss  of  reflexes.  From  cerebral 
lesions  tumors  of  the  cord  can  be  recognized  by  the  localization  of  the 
symptoms  below  a  certain  area  of  the  cord,  the  absence  of  involvement 
of  the  face,  or  mental  functions,  and  the  involvement  of  the  bladder 
and  rectum. 

The  diagnosis  of  the  character  of  the  tumor  can  only  be  made  in 
a  presumptive  way  from  the  associated  symptoms.  Thus  in  a  case 
where  there  is  tuberculosis  elsewhere  in  the  body,  a  family  history  of 
tuberculosis,  and  no  evidence  of  bone  disease,  a  presumptive  diagnosis 
of  a  tuberculous  tumor  can  be  made.  If  there  is  a  history  of  inherited 
or  acquired  syphilis,  or  if  there  is  evidence  of  active  syphilis  elsewhere 
in  the  body,  or  a  previous  history  of  such,  a  gumma  is  diagnosed.  If 
there  is  a  history  of  echinococcus  infection  elsewhere  in  the  body,  and 
there  is  a  variation  in  the  intensity  of  the  pressure  symptoms  with 
minor  destructive  symptoms,  a  cyst  may  be  diagnosed.  If  these  forms 
of  tumors  be  excluded  a  glioma  or  sarcoma  may  be  present.  The  deter- 
mination of  the  character  of  tumor  is  always  more  or  less  guesswork 
and  unsatisfactory. 

Prognosis. — Prognosis  in  all  forms  of  tumor,  with  the  exception  of 
gummata  and  of  simple  cysts,  is  unfavorable.  In  gumma  and  in  other 
forms  of  syphilis  of  the  cord  the  prognosis  will  depend  entirely  upon 
how  early  the  treatment  is  begun  and  how  vigorously  it  is  carried  out. 
When  destruction  of  tissue  has  already  taken  place  little  result  may 
be  expected  from  treatment.  In  all  other  forms  of  tumors,  while  they 
occasionally  yield  to  medical  treatment,  the  only  hope  for  the  patient  is 
in  an  operation.  When  it  is  remembered  that  tumors  of  the  spinal  cord 
in  children  are  very  rare,  and  that  early  life  is  a  deterrent  to  most  opera- 
tors for  a  serious  operation  on  the  nervous  system,  little  can  be  gained 
from  statistics.  Statistics  upon  operations  on  the  nervous  system, 
whether  considered  here  or  elsewhere  in  this  chapter,  should  not  be 
given  too  much  weight,  because  in  rare  operations  we  are  much  more 
likely  to  find  a  successfully  treated  case  placed  on  record  than  one  in 
which  the  results  are  bad  or  where  there  is  a  fatal  outcome. 

Treatment. — When  a  tumor  is  diagnosed  the  question  of  surgical  pro- 
cedure should  be  immediately  considered.  Two  or  three  weeks  may  be 
devoted  to  the  administration  of  mercury  and  iodide,  and  if  no  positive 
results  are  secured  and  the  case  is  otherwise  favorable,  an  operation 
should  be  done.  While  the  results  of  operation  are  too  often  unsatis- 
factory it  is  the  only  hope,  after  medical  treatment  has  been  tried,  in 


908  DISEASES  OF  THE  NERVOUS  SYSTEM 

keeping  tlic  patient  from  a  fatal  termination  or,  at  the  best,  a  life  of 
chronic  invalidism.  Operations  for  simj)le  cystic  formations  of  the 
menin<j;es  j)ressinti;  on  the  spinal  cord  may  be  completely  snccessful  if 
the  patient  withstands  the  shock  of  the  operation.  A  case  of  this  kind 
was  recently  reported  by  Spiller. 


TRAUMATIC  INJURIES  OF  THE  CORD. 

A.  Concussion  of  the  Spinal  Cord. — This  subject  has  given  rise  to 
so  nnich  (Hscussion  in  connection  with  the  subject  of  railway  injuries, 
in  a  medico-leiral  relation,  that  a  definition  of  exactly  what  is  meant  is 
quite  necessary.  The  molecular  changes  of  the  older  writers  are  too 
hypothetical  for  consideration.  A  sudden  traiunatism  without  other 
injury  of  the  spine  or  cord  may  give  rise  to  capillary  extravasations  of 
blood,  degeneration  of  the  sheaths  of  the  nerves,  and  a  secondary  over- 
growth of  neuroffliar  tissue,  eitliei'  localized  to  the  cervical  enlarofement 
of  the  cord  or  ditl'usely  distributed  throughout  the  entire  cord.  Such 
results  may  be  seen  in  the  spinal  cords  of  patients  dying  from  inter- 
current diseases  after  falls  from  a  height  or  after  railway  accidents. 
Identical  lesions  have  l)een  experimentally  produced  in  the  lower  animals. 
The  results  of  this  condition  apart  from  the  shock  produced  are  as 
follows : 

There  may  be  at  first  a  paralysis  or  marked  weakness  of  all  four 
extremities,  which  is  recovercfl  from  in  the  course  of  a  few  days  or 
weeks,  and  is  followed  l)y  a  semispastic  condition  of  the  muscles  with 
awkwardness  and  stiffness  of  movement  and  a  marked  excitation  of  all 
the  reflexes.  In  severe  cases  in  the  early  stages  all  forms  of  sensation 
may  be  lost,  or  only  sensation  for  pain  and  temperature.  In  other  cases 
there  is  no  disturbance  of  sensation;  in  still  othei-s  there  is  anesthesia 
limited  to  one  side  of  the  body,  due  to  hysteria.  From  the  minor  ultra- 
microscopic  changes  of  the  nerve  fibres  and  cells  and  slight  capillary 
hemorrhage  to  extensive  destructive  hemorrhages  many  gradations  may 
be  observed. 

Prognosis. — This  will  depend  on  the  extent  of  the  damage  to  the  cord. 
In  mild  cases  complete  recovery  takes  place  in  a  few  months.  In  other 
cases  permanent  loss  of  power  and  wasting  in  the  arms  occurs. 

Treatment. — Rest  in  bed,  with  massage,  galvanism  and  graduated 
exercises  are  indicated. 

B.  Hemorrhage  of  the  Cord. — There  may  be  a  hemorrhage,  local 
or  extensive  in  character,  into  the  cord  tissiics,  with  partial  or  complete 
destruction,  or  the  hemorrhage  may  surroimd  the  cord.  In  children 
this  condition  is  practically  always  due  to  traumatism.  The  hemor- 
rhage is  usually  the  result  of  a  fall  of  a  considerable  distance,  where  the 
child  lands  in  such  a  way,  either  on  the  feet,  the  shoulders,  or  all  four 
extremities,  as  to  dissipate  the  force  without  frac-ture  or  dislocation  of 
the  spine.  The  vessels  in  the  gray  matter  of  the  spinal  cord  are  so 
poorly  supported  by  surrounding  tissue  that  a  rupture  occurs,  and  a 


DISEASES  OF  THE  SPINAL  CORD  909 

local  hemorrhage  confined  to  the  gray  matter  sufficiently  extensive  to 
involve  the  white  matter  or  to  destroy  the  entire  cross-section  of  the 
cord  at  this  point,  or  in  rare  cases  several  segments  of  the  cord,  is  pre- 
sented. In  the  case  above  referred  to  in  myelitis  an  extensive  area  of 
the  dorsal  cord  vv^as  destroyed  by  hemorrhage  into  the  cord  due  to 
traction  on  the  feet  at  birth.  Practically  the  same  causes  operate  in 
the  production  of  meningeal  hemorrhage. 

Symptomatology. — The  onset  is  sudden  at  the  time  of  the  accident. 
If  the  hemorrhage  be  confined  to  the  gray  matter  of  the  cervical  enlarge- 
ment there  is  at  first  complete  paralysis  of  all  four  extremities,  with  loss 
of  sensation  up  to  the  upper  border  of  the  lesion.  After  a  few  days  the 
edema  of  the  cord  tissue  surrounding  the  hemorrhage,  which  has  led 
to  the  pressure  causing  the  symptoms  of  the  transverse  lesion  at  this 
point,  subsides  and  function  rapidly  returns  in  the  lower  extremities. 
One  or  both  arms  remain  partially  or  completely  paralyzed,  with  loss 
of  reflexes  and  wasting  in  the  paralyzed  parts.  This  is  due  to  the 
destruction  of  the  anterior  horn  cells  by  the  hemorrhage.  While  in 
some  cases  sensation  completely  returns,  in  ether  cases  the  pain  and 
temperature  fibres  are  interfered  with  either  in  their  course  through  or 
in  the  neighborhood  of  the  gray  matter,  and  a  loss  of  sensation  to  pain 
and  temperature  impressions,  persists  for  some  time,  while  sensation  for 
touch  remains  perfectly  normal. 

If  the  entire  segment  of  the  cord  in  its  cross-section  be  destroyed 
there  is  a  complete  loss  of  all  function  below  the  point  of  lesion.  Par- 
alysis of  the  arms  will  be  flaccid  and  wasting;  paralysis  of  the  legs  spastic 
with  increased  reflexes,  the  Babinski  reflex,  ankle  clonus,  and  incon- 
tinence of  retention  of  urine  will  be  present. 

In  hemorrhage  into  the  lumbar  enlargement  the  paralysis  is  confined 
to  the  legs,  is  of  the  flaccid,  degenerating  type,  with  loss  of  reflexes 
and  incontinence  of  urine.  In  a  case  with  a  small  hemorrhage  into  the 
sacral  cord  there  was  paralysis  of  the  calf  muscles,  atrophic  ulcer  of  the 
sole  of  the  foot,  incontinence  of  urine,  and  a  saddle-shaped  area  of 
anesthesia  of  the  posterior  surface  of  the  thighs,  all  of  which  developed 
suddenly  after  great  overexertion. 

Hemorrhages  into  the  meninges  of  the  cord  are  due  to  the  same 
causes  as  those  of  hemorrhages  into  the  cord,  and  produce  symptoms  of 
pressure  on  the  cord  which  rapidly  subside.  A  sudden  paralysis  of 
motion  and  sensation  below  the  area  of  hemorrhage,  with  some  lancin- 
ating pain  due  to  the  irritation  of  the  roots,  develop  at  the  time  of  the 
hemorrhage.  These  symptoms  rapidly  disappear  and  may  leave  no 
results,  or  there  may  be  evidence  of  chronic  irritation  at  the  point  of 
lesion  due  to  organization  of  the  clot. 

Treatment. — The  treatment  follows  the  same  lines  as  that  described 
under  Myelitis. 

Prognosis. — This  depends  in  a  study  of  each  case.  When  there  is 
extensive  loss  of  nerve  tissue,  very  little  return  of  power  is  to  be  ex- 
pected. In  meningeal  hemorrhage  rapid  and  complete  return  of  func- 
tion is  the  rule.     Irritative  symptoms  sometimes  persist.     Traumatic 


910  DISEASES  OF  THE  NERVOUS  SYSTEM 

liystcria  or  neurasthenia  may  complicate  the  clinical  picture  and  persist 

for  a  loiio-  time  after  tlic  otlier  symptoms  liave  disappeared. 

C.  Fracture  and  Dislocation  of  the  Spine. — Tlie  results  due  to  both 
of  these  conditions  are  practically  the  same.  In  either  case  the  cord  is 
pressed  upon  and  is  crushed  or  completely  destroyed.  Any  part  of  the 
spinal  cord  may  be  injured,  the  (lorsal  cord  being  most  frecjuently 
aH'ected.  There  is  usually  comj>lete  loss  of  function  below  this  area. 
Paralysis  is  spastic  in  type,  with  increase  of  the  reflexes  and  incon- 
tinence of  retention  of  urine.  The  upper  border  of  the  lesion  may  be 
diagnosed  by  the  determination  of  the  upper  limit  of  loss  of  sensation. 
The  lower  limit  may  be  determined  by  the  area  of  preservation  of 
reflexes.  Thus  in  a  case  of  crush  of  the  cord  due  to  fracture,  with  exten- 
sive bone  tenderness  and  crepitus  in  the  lower  dorsal  area,  the  upper 
limit  of  anesthesia  corresponded  to  the  first  lumbar  segment,  the  pres- 
ervation of  the  knee-jerk  indicating  that  the  third  lumbar  segment  at 
least  was  functionally  intact. 

Treatment. — The  only  treatment  is  operation.  The  results  of  opera- 
tive treatment  in  the  large  majority  of  cases  of  injury  to  the  spine  luis 
given  very  poor  results  for  the  return  of  function  after  the  relief  of  j)res- 
surc.  The  spinal  cord  is  usually  so  crushed  that  little  result  can  be  ex- 
pected. Even  where. the  resthution  of  nutrition  of  the  intraspinal  tissue 
is  secured  the  restitution  of  function  is  usually  a  very  slow  process,  and 
is  a  matter  of  months  or  even  years  until  the  maximum  results  are  ob- 
tained. The  treatment  of  the  patient  whether  operation  be  attempted 
or  not  does  not  differ  essentially  or  even  in  detail  from  that  given  above 
for  myelitis.  Suture  of  the  spinal  cord  has  been  attempted  in  one  case, 
but  the  return  of  power  has  been  unsatisfactory. 


SYPHILITIC  DISEASE  OF  THE  SPINAL  CORD. 

Syphilis  of  the  Spinal  Cord  in  children  is  usually  the  result  of 
hereditary  syphilis,  but  not  infrequently  cases  occur  of  infection  of 
children  by  the  parents  or  accidentally  from  others.  I  have  in  mind  a 
family  in  which  four  children  and  their  mother  presented  evidence  of 
active  accpiired  syphilis  from  a  drunken  and  dissolute  father.  In  the 
ac(juired  form  of  syphilis  the  disease  may  follow  the  type  of  syphilis  of 
the  nervous  system  in  the  adult.  In  the  hereditary  form  there  may  be 
active  syphilitic  manifestations,  or  the  resistance  of  the  nervous  system 
to  external  infections  may  be  lowered.  The  gumma  as  a  symptom 
of  tertiary  sy])hilis  acquired  or  inherited  has  already  been  eonsidereil 
untler  the  subject  of  Tumors  of  the  Spinal  Cord.  The  other  conditions 
met  with  in  the  spinal  cord  are  myelitis  and  meningomyelitis.  The 
myelitis  does  not  differ  from  that  due  to  other  causes,  and  may  be  acute, 
subacute,  or  chronic.  There  is,  however,  in  these  cases  a  more  marked 
involvement  of  the  bloodvessels  and  resulting  endarteritis.  It  is 
usually  a  manifestation  of  secondary  syphilis,  although  the  chronic 
forms  may  occur  in  the  tertiary  stage.     While  the  myelitis  may  occur 


DISEASES  OF  THE  SPINAL  CORD  911 

alone,  it  is  usually  associated  with  inflammation  of  the  surrounding 
membranes  of  the  cord.  It  is  rare  to  have  an  inflammation  of  the 
meninges  of  the  spinal  cord  without  involvement  of  the  cord  tissue. 
To  this  combination  the  term  meningomyelitis  has  been  given. 

Symptomatology. — The  symptoms  of  an  acute  syphilitic  myelitis 
localized  to  one  part  of  the  spinal  cord  do  not  differ  from  those  due  to 
other  causes  and  described  above.  In  the  subacute  and  chronic  forms, 
where  there  is  an  associated  involvement  of  the  membranes  and  the 
bloodvessels  in  an  irregular  way  over  extensive  areas  of  the  cord,  the 
symptoms  follow  a  rather  irregular  distribution,  depending  entirely 
upon  the  cord  tissues  involved.  Inasmuch  as  the  dorsal  cord  bears  the 
brunt  of  the  attack  in  the  majority  of  cases,  the  most  common  manifes- 
tation of  subacute  and  chronic  syphilis  is  a  paraplegia,  spastic  in  type, 
developing  rather  slowly,  but  at  times  following  evidences  of  a  rather 
acute  inflammatory  process,  and  associated  with  increase  of  the  reflexes 
and  involvement  of  the  bladder  function.  As  the  disease  progresses 
the  other  tracts  of  the  spinal  cord  are  involved  and  irregular  areas  of 
loss  of  sensation  on.  the  trunk  and  the  extremities  are  present.  When 
the  meningeal  process  extends  to  the  lumbar  enlargement  some  of  the 
anterior  roots  are  involved,  and  irregular  atrophy  of  one  extremity  or 
some  groups  of  muscles  results.  The  reflexes  in  the  atrophic  distribu- 
tion become  diminished  and  are  finally  lost,  while  in  the  muscles  which 
remain  intact  and  spastic  they  are  persistent  and  increased.  When 
the  process  extends  to  the  cervical  enlargement  there  may  be  an 
atrophy  of  a  single  group  of  muscles  or  of  one  arm,  and  perhaps  asso- 
ciated with  a  spastic  condition  of  the  opposite  arm,  or  this  arm  may 
remain  perfectly  free,  or  there  may  be  simply  loss  of  power  with  atrophy 
affecting  the  muscles  of  the  hand.  Sensory  disturbances  may  be  present 
in  the  arms  when  the  posterior  roots  become  involved.  Irritation  of 
the  posterior  roots,  transmitting  the  pain  impressions  from  the  periphery 
to  the  spinal  cord,  may  result  in  constant  or  intermittent  lightning-like 
pains  referred  to  any  portion  of  the  body,  depending  entirely  upon  the 
roots  affected.  A  careful  history  of  the  disease  will  reveal  a  continuity 
or  regular  sequence  of  the  symptoms  depending  upon  the  pathological 
process,  beginning  in  one  area  of  the  cord  and  extending  in  its  irregular 
way  along  the  meninges  with  the  involvement  of  the  underlying  cord 
tissue.  There  is  in  these  cases  only  an  apparent  irregularity  and  atypical 
arrangement  of  the  symptoms,  and  if  the  case  be  studied  with  the  exten- 
sion of  the  pathological  process  in  mind,  and  the  anatomy  and  physiology 
of  the  cord  involved  be  taken  into  consideration,  the  clinical  picture  can 
easily  be  understood  and  interpreted.  It  is  neither  right  nor  scientific 
to  make  a  diagnosis  of  syphilis  of  the  cord  simply  because  the  symptoms 
presented  do  not  fit  into  the  picture  described  for  other  diseased  types. 

Diagnosis. — The  diagnosis  must  depend  to  a  great  extent  on  the  rule 
of  the  extension  of  the  process  laid  down  above,  and  especially  upon 
the  history  of  the  case  and  other  evidences  of  somatic  syphilis.  The 
spastic  form  may  be  mistaken  for  the  cerebral  palsies  of  childhood,  and 
especially  for  that  form  in  which  both  legs  are  affected.     The  absence 


912  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  local  alroj)liy,  tlio  increase  of  all  the  roflex(\s  of  the  lower  extroinity, 
the  ahseiice  of  involvcMiient  of  sensation  of  a  spinal  ty])e,  the  history  of 
clifHcnlt  or  prolon^ied  labor,  and  the  lack  of  otiier  evidence  of  syphilis 
in  cerebral  })alsies  will  make  the  diagnosis.  Acnte  anterior  poliomyelitis 
can  easily  be  differentiated  from  syphilis  by  the  absence  of  disturbance 
of  sensation,  of  pain,  and  a  normal  condition  of  the  reflexes  of  the 
rest  of  the  body,  with  loss  of  reflexes  in  the  area  of  paralysis.  Even 
in  those  cases  of  poliomyelitis  where  there  is  more  than  one  focus  of 
inflammation  and  where  an  arm  on  one  side  and  a  leg  on  the  opposite 
side  may  be  paralyzed,  or  where  an  arm  or  leg  on  the  same  side  may  be 
aft'ect(>d,  the  acute  onset  of  the  disease  and  the  absence  of  sensory  or  pain 
syni])toms  will  usually  be  sufficient  to  make  a  diagnosis.  In  those  cases 
where  a  gumma,  a  myelitis,  and  extensive  involvement  of  the  meninges 
are  associated  in  a  single  case  the  mere  combination  of  the  three  sep- 
arate groups  of  symptoms  will  point  to  syphilis  as  the  causative  factor. 

Treatment. — INIercury  and  the  iodides  give  good  results,  when  adminis- 
tered before  tlestructive  connective-tissue  changes  take  place;  when 
given  late  they  are  of  little  benefit. 


DISSEMINATED  SCLEROSIS.    MULTIPLE    SCLEROSIS. 

While  cases  of  Disseminated  Sclerosis  first  come  under  observation 
during  the  second  decade  of  life,  there  is  little  doubt  that  in  a  large 
number  of  cases  not  only  are  the  symptoms  ])resent  during  the  first 
decade  of  life,  but  may  be  present  even  at  birth  (Totzke). 

Etiology. — The  disease  is  commonly  regarded  as  associated  with  the 
infccticHis  diseases  of  childhood,  but  it  may  not  fc^llow  until  some  vears 
after  an  infectious  fever.  It  may  occasionally  develop  immediately  after 
an  injury.  Oppenheim  has  insisted  on  the  toxic  nature  of  this  affection 
and  has  directed  attention  to  the  influence  of  metallic  poisoning  as  a 
factor  in  its  protluction.  The  occurrence  of  the  disease  at  birth  and 
of  cases  fountl  in  succeeding  generations  has  led  some  to  consider  it  an 
hereditary  type  of  disease.  Direct  heredity,  however,  is  as  rare  in  this  as 
in  otiier  forms  of  organic  nervous  disease. 

Pathology. —  Irregular  patches  of  sclerosis  are  found  in  almost  every 
portion  of  the  central  nervous  system.  They  are  more  frequent  in  the 
white  matter  of  the  brain,  in  tfie  pons  and  medulla,  and  usually  in  a 
symmetrical  way  in  the  posterior  half  of  the  spinal  cord.  The  areas  of 
.sclerosis,  however,  follow  no  definite  rule  of  location  and  may  occur 
anywhere.  There  is  a  certain  vague  relation  in  their  early  formation 
to  the  distribution  of  the  bloodvessels.  Microscopic  examination  shows 
in  the  early  stages  patches  of  sclerosis  surrounding  the  bloodvessels 
with  proliferation  of  the  neurogliar  cells,  destruction  of  the  myelin 
sheaths  of  the  nerve  fibres,  but  with  a  preservation  of  the  axis  cylinders 
in  the  sclerotic  areas. 

Symptomatology. — The  symptoms  presented  are  at  first  weakness  of 
the  lower  extremities  followed  by  a  similar  condition  of  the  upper 


DISEASES  OF  THE  SPINAL  CORD  913 

extremities,  with  increase  of  the  reflexes  and  a  spastic  gait.  A  charac- 
teristic intention  tremor  develops  early.  There  may  be  no  tremor  of 
the  hands  at  rest,  but  when  some  voluntary  action  is  attempted  a  coarse 
tremor  becomes  so  marked  as  to  prevent  the  patient  feeding  or  caring 
for  himself.  The  speech  about  this  time  becomes  afl'ected  and  presents 
a  slow,  deliberate,  tremulous,  scanning  quality.  An  examination  of  the 
eyes  shows  a  marked  oscillation  of  the  eyeball  from  one  side  to  the 
other  on  lateral  movement.  An  examination  of  the  eye  fundus  usually 
shows  a  marked  pallor  of  the  temporal  side  of  the  nerve  head  due  to 
patches  of  sclerosis  in  the  optic  nerve  or  the  optic  commissure.  The 
pupils  are  more  or  less  contracted  and  react  somewhat  sluggishly  to 
light  and  accommodation.  In  rare  cases  there  may  be  no  reaction  to 
light,  but  reaction  to  accommodation  is  retained.  The  memory  not 
infrequently  becomes  weakened  and  the  other  intellectual  faculties 
may  be  likewise  impaired.  The  combination  of  the  intention  tremor 
with  nystagmus,  scanning  speech,  and  mental  defect  is  characteristic 
of  this  affection.  If  to  this  be  added  irregular  manifestations  due  to 
patches  of  sclerosis  anywhere  in  the  brain  or  cord  a  diagnosis  can  easily 
be  made.  When  the  lesions  first  develop  in  the  cord  the  diagnostic 
symptoms  may  not  develop  for  several  years. 

In  one  case  a  patch  of  dense  sclerosis  in  the  posterior  columns  led  to 
a  diagnosis  of  locomotor  ataxia,  which  was  changed  after  two  years  by 
another  observer  to  ataxia  paraplegia.  This  was  due  to  an  involvement 
of  both  lateral  columns  of  the  cord  by  irregular  patches  of  sclerosis  in 
the  interval.  A  year  later  the  loss  of  power  in  the  lower  extremities  was 
so  complete  and  the  spasticity  so  marked,  due  to  a  lesion  high  up  in  the 
dorsal  cord  which  involved  the  entire  area  of  cross-section,  that  a  diag- 
nosis of  spastic  paraplegia  was  made  by  a  third  observer.  The  lesions 
in  this  case,  which  were  so  long  confined  to  the  spinal  cord,  had  they 
been  associated  with  the  symptoms  due  to  involvement  of  the  cervical 
enlargement  of  the  cord,  the  medulla,  and  the  pons,  would  have  led  to 
an  easy  diagnosis.  The  examination  of  the  eye-grounds  in  this  case  apart 
from  the  above  symptoms  would  have  shown  the  irregular  areas  of 
whitening  of  the  disks  due  to  patches  in  the  optic  nerves  and  commissure. 

In  some  cases  when  the  patches  of  sclerosis  affect  the  anterior  horns 
of  the  spinal  cord  atrophy  of  the  muscles  develops.  The  involvement  of 
sensation  is  irregular  and  depends  upon  the  patches  of  sclerosis  in  the 
spinal  cord.  Areas  of  anesthesia  present  at  one  time  during  the  disease 
may  disappear  if  the  axis  cylinders  running  through  the  sclerotic  patches 
do  not  undergo  complete  degeneration.  Paralysis  of  the  cranial  nerves 
also  occurs,  particularly  of  those  nerves  supplying  the  ocular  muscles. 

Diagnosis. — Muhiple  sclerosis  occurring  in  childhood  and  presenting 
the  scanning  speech,  the  nystagmus,  the  intention  tremor,  and  mental 
defects  is  not  likely  to  be  mistaken  for  any  other  condition.  There 
are  cases,  however,'  which  have  been  diagnosed  in  the  early  stages  as 
chorea  or  spastic  spinal  paraplegia.  In  such  cases  time  aids  in  the 
diagnosis  and  the  examination  by  the  ophthalmoscope  revealing  changes 
in  the  optic  disk  as  mentioned  above  will  be  of  considerable  value. 
58 


914  DISEASES  OF  Tin:  MUlVOrs  SYSTEM 

Prognosis. —  I'r()<;ii()sis  as  far  as  life  is  coiiccriicd  is  ^ood.  Cases 
l)c<;iiiiiiti^  in  childliociil  rarely  lixc  Ixyniid  niiddjc  lil'e.  'I'licrc  is  no 
liojw  for  cure. 

Treatment. — The  treatiiu-iit  of  a  disease  of  a  type  recoijiiized  from 
tlie  he^imiiiitf  to  he  iiieiiral)le  must  he  iu  the  (hreetion  of  makiuj;  tlie 
patient  c-omfortahl(>.  Tliis  is  hest  secured  hy  attention  to  the  general 
liv<;iene,  the  avoi(hinee  of  fatigue  and  j)rolon^e(|  hotu's  of  rest.  The 
tremor  is  to  a  certain  extent  controlled  hy  keej)in;^  the  muscles  in  <^o()d 
condition,  hy  massage,  electricity  (galvanism),  and  hydrotherapy.  A 
tepi<l  or  warm  hath  associated  with  gentle  massai^e  <;ives  the  hest  tffect. 
Many  dru<;s  have  hcen  \\svi\  with  nc^Mtive  results.  The  iodides,  bro- 
mides, UK'nurials,  and  nitrate  of  sihcr  are  the  favorites. 


ABIOTROPHIC  DISEASES. 

flowers  has  recently  used  the  term  .Vhiotrophy  to  desi^nat(>  that  con- 
dition of  tissues  in  which  there  is  an  inherent  defect  or  lack  of  vital!) \. 
This  is  manifested  hy  an  early  de<;eneration  or  loss  of  function  of  the 
tissues  alVccted.  The  class  of  diseases  referalde  to  the  nervous  system 
which  we  shall  consider  as  helon^nui,'  to  tiiis  ^rou]>  are:  a.  Hereditary 
ataxia  (Friedreich's  ataxia),  h.  Hereditary  s])astie  paralysis,  c.  Mus- 
cular dvstropliics. 

HEREDITARY  ATAXIA. 

Hei-e(litary  .\ta\ia,  or  h^riedreich's  Ataxia,  is  essenlially  a  disease  of 
childhood.  Friedreich  in  desci-il)in<;  this  disease  in  \S{)'.>  considered  it 
a  juvenile  form  of  locomotor  ataxia,  and  called  attention  to  its  con<fcnital 
origin  and  to  the  fact  that  it  alfected  several  memiu'rs  of  the  same 
family. 

Etiology.  l''rie(lreich's  disease  always  occurs  in  earlv  life  (Fi<,f.  IS2). 
It  is  usually  fully  developed  before  the  second  decade.  Cases  (lev(>lo|)- 
ing  after  this  period  are  always  open  to  the  sus|)icion  of  belonsrini;  to 
some  other  disease  group.  Of  the  143  ca.ses  collected  by  (iriilith  b") 
occurred  before  the  age  of  two  years,  .'iO  between  the  second  and  sixth 
year,  4.')  between  the  sixth  and  tenth  year,  20  between  the  eleventh  and 
fifteenth,  bS  iM'tween  the  sixteenth  and  twentieth,  and  5  between  the 
twentieth  and  twenty-fifth  year;  SC)  were  males  and  .I?  females.  Some 
ca.se.s  have  followed  the  infectious  fevers,  but  they  are  factors  only 
in  so  far  as  they  develop  an  inherent  abiotrophy.  Oppenheim  has 
considered  an  iidierited  syj)hilis  to  be  a  factor;  he  has,  however,  found 
few  to  a;,M-ee  with  him. 

Pathology. — Crossly  the  sj)inal  cord  is  smaller  than  normal.  The 
microscopic  examination  shows  an  extensive  degeneration  in  the  ])oste- 
rior  and  lateral  colunms.  The  degeneration  is  associated  with  an  ext<Mi- 
sive  sclerosis  in  the  columns  of  Coll  and  Hurdach,  more  marked  in  the 
former,  and  a  lesser  grade  of  .sclerosis  in  the  crossed  pyramidal  motor 
tracts,  and  of  Clarke's  column  of  ganglion  cells  in  the  j)osterior  grav 


ABIOTBOPHIC  DISEASES 


915 


Fig. 182 


horns.  The  degeneration  of  the  spinal  cord  extends  as  far  as  the  medulla. 
Atrophy  of  the  posterior  roots  and  of  the  peripheral  nerves  has  been 
described.  Recent  careful  examinations  of  the  rest  of  the  spinal  cord 
have  shown  a  defective  development  (diminution  of  the  number  of 
fibres  in  areas  not  affected  by  the  sclerosis). 
There  are  also  fewer  ganglion  cells  in  the  an- 
terior and  posterior  horns  than  in  normal  cords. 
INIarchi  has  stated  that  secondary  changes  are 
present  in  the  cerebellum.  There  is  therefore  a 
marked  degeneration  with  sclerosis  affecting 
both  motor  and  sensory  paths  and  evidence  of 
defective  development  of  the  other  cord  tissues. 
Symptomatology. — The  disease  may  be  con- 
genital and  an  absence  of  motor  power  be  pres- 
ent from  birth.  These  children  never  develop 
the  power  to  stand  or  walk  and  eventually  pre- 
sent the  same  clinical  picture  as  found  in  those 
who  acquire  the  disease  later.  As  will  be  seen 
from  the  tables  quoted  most  cases  begin  between 
the  fifth  and  tenth  years  of  life.  A  careful  his- 
tory will  usually  show  some  manifestations 
prior  even  to  this  time.  When  the  child  learns 
to  walk  it  is  often  found  that  he  is  unsteady  on 
his  feet  with  an  awkward  staggering  gait.  If  he 
has  already  learned  to  walk  an  ataxia  of  the  lower 
limbs  is  first  manifested;  the  gait  is  unsteady 
and  swaying,  the  legs  spread  apart,  and  the 
foot  brought  down  with  a  sudden  stamp,  very 
much  the  same  but  not  so  marked  as  that  seen 
in  locomotor  ataxia.  When  the  child  tries  to 
stand  he  sways  from  side  to  side  and  if  the 
feet  are  approximated  there  is  distinct  oscillation 
of  the  body  due  to  an  attempt  in  the  weakened 
muscles  to  preserve  the  balance.  After  the  ataxia 
is  well  developed  rigidity  of  the  limbs  due  to  an 
affection  of  the  motor  tract  in  the  lateral  columns 
becomes  manifest.  There  is  now  added  a  spas- 
tic element  to  the  gait  with  a  tendency  to  drag 
the  feet  and  muscular  weakness.  Even  in  this 
early  stage  of  the  disease  an  examination  of  the 
eyes'  will  show  a  lateral  oscillation  of  the  eyeball 
on  attempted  movements;  there  is,  however, 
no  affection  of  the  ocular  muscles  or  the  optic 
disk.  In  advanced  cases  the  rigidity  of  the  lower 
extremities  becomes  marked,  the  loss  of  power 
almost  complete,  the  reflexes  abolished,  and  the  arms  so  ataxic 
attempts  at  movement  results  in  irregular,  slow,  choreic-like  movements. 
There  may  be  also  some  loss  of  power  in  the  arms.    Speech  is  now  slow, 


Friedreich's  hereditary 
ataxia.  The  awkward  posture 
and  forward  bending  of  the 
body  are  noticeable  ;  also  the 
slight  flexion  of  knees  and 
elbows.    (Starr.) 

that 


916  DISEASES  OF  THE  NERVOUS  SYSTEM 

iiulistiiKt,  aiul  tlifiicult,  with  fibrillary  tremors  of  the  tongue.  The 
sensation  is  usually  normal  and  becomes  affected  only  late  in  the  disease. 
There  is  usually  no  pain  and  no  disturbance  of  the  function  of  the  blad- 
der or  rectum.  In  the  advanced  cases  the  feet  present  a  very  characteristic 
deformity;  they  are  apparently  shortened  and  in  a  condition  of  pes 
cavus;  the  toes  are  hyperextended,  and  this  is  especially  true  of  the 
great  toe,  which  is  drawn  back  like  a  hook.  The  mentality  of  those 
affected  is  usually  defective;  they  are  educated  with  difficulty,  and 
remain  in  a  l)ackward  or  even  infantile  mental  condition. 

Prognosis. — Prognosis  is  favorable  as  to  life  and  absolutely  unfavor- 
able as  to  cure.  There  is  no  known  method  of  treatment  which  can 
appreciably  affect  the  progressive  course  of  the  disease. 

Diagnosis. — The  only  condition  from  w'hich  it  is  to  be  differentiated 
is  a  cerebellar  form  of  ataxia  described  by  INIarie.  This  disease  was 
first  described  by  Marie  and  has  the  titubation,  ataxia,  tremor  of  the 
head  and  of  the  extremities,  and  the  nystagmus  seen  in  Friedreich's 
ataxia.  It,  however,  differs  in  several  essential  particulars.  Atrophy 
of  the  cerebellum  has  been  foimd  in  three  cases.  The  spinal  cord  was 
not  diseased.  Hereditary  cerebellar  ataxia,  however,  comes  on  after 
the  age  of  puberty  with  some  loss  of  ])ower  in  the  legs  and  a  moderate 
ataxia,  but  not  so  marked  as  that  of  Friedreich's  disease.  There  are 
marked  disturbances  of  sensation.  Amblyopia  and  contraction  of  the 
visual  fields  due  to  atrophy  of  the  optic  nerve  may  be  present.  Diplopia 
and  color  l)lindness  have  also  been  described.  The  extensive  deformity 
of  the  foot  and  the  kyphosis  of  Friedreich's  ataxia  are  not  present. 
This  is  also  a  family  disease  and  several  members  of  the  same  family 
may  be  affected. 

Treatment. — The  prognosis  and  treatment  are  as  hopeless  in  the 
cerebellar  form  of  ataxia  as  in  Friedreich's  ataxia. 

While  nothing  can  be  done  to  cure  either  one  of  the  above  diseases, 
nmch  may  be  done  to  prolong  life  and  to  make  the  patient  comfortable. 
Attention  to  the  l)0(ly  functions  and  especially  to  nutrition  and  to  the  gas- 
troenteric tract,  ])lenty  of  fresh  air  and  sunshin(>,  and  mild  massage  asso- 
ciated with  hydrotherapy  to  assist  in  keeping  the  muscular  system  in 
good  condition,  give  better  results  than  medicinal  measures.  In  the  later 
stages  care  should  be  taken  to  prevent  contractures  and  deformity. 
Not  only  does  section  of  the  tendons  relieve  the  deformity,  but  often 
overcomes  the  increased  tension  and  by  the  resulting  relaxation  of  the 
muscles  relieves  the  discomfort  or  even  pain  due  to  spasm.  Death  oc- 
curs after  years  of  invalidism  from  some  intercurrent  affection. 


HEREDITARY  SPASTIC  PARALYSIS. 

Hereditary  Spastic  Paralysis,  or  Family  Spastic  Paralysis,  is  a  condi- 
tion of  spastic  paralysis  affecting  the  lower  extremities,  at  times  to  a 
slight  degree  the  upper  extremities,  and  occurring  as  a  family  disease 
with  heredity  as  an  important  factor.    It  may  be  due  to  different  causes. 


ABIOTROPHIC  DISEASES 


917 


Practically  all  of  these  cases,  however,  depend  on  an  abiotrophy  and 
a  defective  development  of  either  the  brain  or  of  the  spinal  cord  (Figs. 
183,  184).  We  may  therefore  classify  them  into  two  distinct  types: 
(a)  Those  due  to  a  defective  development  of  the  motor  tracts  (cross 
pyramidal  tracts  of  the  spinal  cord).  (&)  Those  due  to  an  arrested 
cerebral  development. 

(a)  In  the  first  group  of  cases  there  is  no  evidence  of  cerebral  disease. 
There  is  simply  an  affection  of  the  spinal  motor  tracts.     These  may 


Fig.  183 


Fig.  184 


Marked  spastic  paraplegia ;  walking  or  stand- 
ing alone  impossible,    (Dercum.) 


;  paraplegia  ;  crossed-legged  pro- 
gression.   (Dercum.) 


occur  as  isolated  cases  (Little's  disease),  in  groups  in  an  individual 
family  without  previous  heredity,  or  there  may  be  a  history  of  cases  in 
the  immediate  preceding  generation  or  in  collateral  branches  of  the 
family.  They  may  develop  in  early  childhood  or  less  frequently  later 
in  life.  In  a  family  which  recently  came  under  my  observation,  several 
members  presented  a  paralysis,  spastic  in  type,  developing  about  puberty, 
which  was  progressive.  This  family  represented  a  type  of  this  disease. 
There  is  a  development  in  late  childhood  of  a  loss  of  power  associated 
with  spasticity,  a  disturbance  of  the  gait,  and  associated  with  increase  of 
the  reflexes,  the  Babinski  reflex,  and  ankle  clonus.  There  is  no  loss 
of  sensation,  no  disturbance  of  the  bladder  or  rectum,  and  no  true 


918 


DISEASES  OF  THE  NER  VO  US  SYSTEM 


ataxia.  Tht'  mental  condition  of  these  children  and  those  who  have 
gone  on  to  adnlt  lite  is  practically  normal.  There  is  no  evidence  in 
any  of  the  ca.ses  that  accidents  at  birth  or  accjuired  cerebral  di.sease  had 
aught  to  do  with  the  production  of  the  .symptoms.  The  di.sease  is  a 
progressive  one  and  finally  results  in  such  lo.ss  of  power  as  to  confine 
the  patient  to  a  rolling  chair  or  to  bed. 

(/;)  Arrested  Cerebral  Development.  Amourntie  Famihi  Jdioey. — Cases 
of  this  kind,  first  described  by  Freud  and  Sachs,  of  New  York,  occa- 
sionally occur.  Most  of  them  are  .seen  in  Jewish  families.  A  child 
who  is  born  apparently  healthy  and  of  good  physical  and  cranial 
development  tloes  well  for  .several  months  to  a  year  and  then  begins  to 
show  evidence  of  arrested  cerebral  develoj>inent.  The  mental  faculties 
either  come  to  a  stand.still  or  retrogress  and  a  condition  of  idiocy  is 
presented.    Nystagmus  occurs  and  is  associated  with  progressive  blind- 


Fig.  185 

1 

^S 

^0^9 

1 

! 

fi 

s^ 

L.  ■  . 

^. 

^^^^^^B^S^^ 

Little's  disease.  Thespastic  rigid  conditionof  the  musclesis  shown  when  Diuchild  isatrest.  Thi 
child  was  very  bright  and  only  presented  the  spastic  condition  of  the  muscles. 


ne.ss.  This  is  due  to  an  atrophy  of  the  optic  nerve  and  a  grayish-white 
opacity  in  the  region  of  the  fovea  centralis.  This  may  be  all  that  is 
presented.  In  other  ca.ses  a  spastic  paraplegia  of  the  lower  extremities 
develops;  there  is  tremor  of  the  arms,  due  probably  to  loss  of  power; 
excessive  slowness  in  whatever  speech  may  be  present,  and  finally 
death  after  one  or  two  years  from  progressive  emaciation.  Convulsions 
are  never  present.  The  pathology  of  this  condition  consi.sts  in  a  com- 
plete arrest  in  the  development  of  the  cells  in  the  cerebral  cortex. 

Diagnosis. — The  diagnosis  of  the  purely  spinal  type  is  comparatively 
easy,  (iiven  .several  members  of  the  same  family  affected  bv  spastic 
paralysis  of  the  lower  extremities  without  sensory  derangement  or  dis- 
turbance of  the  bladder  or  rectum,  there  is  no  other  condition  with 
which  it  could  be  confounded  with  a  possible  exception  of  tho.se  rare 
cases  in  wliich  several  members  of  the  same  family  present  a  cerebral 
form  of  paralysis  due  to  the  fact  that  in  a  contracted  pelvis  in  the  mother 
prolonged  labor,  or  the  application  of  forceps  resulted  in  brain  injuiy 


ABIOTBOPHIC  DISEASES  919 

in  successive  labors.  These  cases  date  from  birth  and  are  associated 
with  convulsions,  marked  mental  defect,  as  a  rule,  and  the  different 
individuals  may  present  different  types  of  paralysis.  (See  Cerebral 
Paralysis  of  Childhood,  p.  957.) 

Amaurotic  family  idiocy  due  to  arrested  cerebral  development 
presents  a  clinical  picture  so  distinctive  and  the  history  of  its  occur- 
rence in  several  members  of  the  same  family  that  it  could  hardly  be 
confounded  with  any  other  disease.  A  brain  tumor  in  a  child  would 
give  blindness  with  motor  symptoms,  but  there  would  in  all  probability 
in  these  cases  be  convulsions  or  other  localizing  symptoms.  The  ophthal- 
moscopic examination  would  undoubtedly  make  the  diagnosis  as  the 
optic  atrophy  and  retinal  changes  of  family  idiocy  are  entirely  unlike 
the  choked  disk  of  brain  tumor. 

Prognosis. — The  prognosis  in  both  class  of  disease  is  unfavorable. 

Treatment. — There  is  no  known  treatment  that  effects  the  course  of 
either. 

PROGRESSIVE  MUSCULAR  DYSTROPHY. 

The  term  Muscular  Dystrophy  will  be  used  in  this  section  to  designate 
a  group  of  diseases  distinctly  localized  to  the  muscular  structures  in 
order  to  distinguish  them  from  another  class  of  diseases  to  which  the 
term  progressive  muscular  atrophy  has  been  applied  and  due  to  disease 
of  the  anterior-horn  cells  of  the  spinal  cord.  It  will  therefore  be  under- 
stood that  unless  otherwise  so  stated  the  central  and  peripheral  nervous 
systems  present  no  pathological  conditions.  Progressive  muscular 
dystrophy  represents  an  abiotrophy  of  the  muscular  tissues.  Any  of 
the  voluntary  muscles  of  the  body  may  be  affected.  Several  types  of 
the  disease  have  been  described,  depending  upon  the  distribution  of  the 
muscles  affected.  There  is  little  necessity  from  a  clinical  or  pathological 
standpoint  of  following  these  artificial  types.  The  different  types 
gradually  merge  one  into  another  and  there  are  cases  which  cannot  be 
assigned  to  any  particular  group.  The  types  described  are  as  follows: 
(a)  Landouzy-Dejerine  type  affecting  the  face  and  shoulder  girdle.  (&) 
Erb's  type,  the  juvenile  form  of  muscular  dystrophy  in  which  the  mus- 
cles of  the  shoulder  girdle,  the  pelvic  girdle,  and  the  back  are  affected, 
(c)  The  pseudohypertrophic  form  of  muscular  dystrophy.  This  refers 
more  to  the  type  of  muscular  change  and  secondary  fat  deposition  than 
to  the  muscles  involved. 

Etiology. — This  disease  occurs  in  families  and  sometimes  all  of  the 
members  of  a  family  are  affected.  There  may  be  a  true  heredity,  several 
generations  being  affected.  More  males  than  females  show  the  disease. 
The  transmission  of  the  disease  is  usually  through  the  mother.  The 
infectious  fevers  and  traumatism  have  been  suggested  as  causative 
factors,  but  are  probably  accidental.  The  disease  represents  an  inherent 
congenital  defect  of  muscle  vitality  leading  to  degeneration  in  certam 
groups  early  in  life.  Members  of  collateral  branches  of  families  may 
be  affected  with  perhaps  only  a  sporadic  case  in  one  family. 

Pathology.— The  most  careful  examination  of  the  brain  and  spmal 
cord  even  in  those  cases  that  have  lasted  many  years  (as  in  Spiller's 


920 


DISEASES  OF  THE  NERVOUS  SYSTEM 


and  Dejerine's  cases)  has  shown  no  change  in  the  central  or  periph- 
eral nervous  systems.  The  examination  of  the  muscles  shows  a 
marked  atrophy  of  the  individual  muscle  fibres  with  an  increase  in 
the  number  of  the  muscle  and  interstitial  nuclei.  With  this  atrophy 
of  the  individual  muscle  fibres  the  striations  are  lost  and  finally  when 
there  is  a  marked  atrophy  of  the  muscle  the  muscle  substance  of  some 
of  the  fibres  disaj)pear,  leaving  the  sheath  filled  with  an  edematous 
exudate  or  its  place  is  taken  by  a  deposit  of  fat. 

In  some  cases  the  interstitial  connective  tissue  is  larger  in  amount 
with  an  increase  in  the  deposition  of  fat.  Individual  muscle  fibres  may 
be  hypertrophied  and  large  giant  muscle  cells  and  fibres  followiug 
the  appearance  of  normal  fibres  may  be  j)resent.     The  proliferation  of 


Fig. 186 


Pseudohypertrophic  muscular  dystrophy.  Four  brothers,  aged  twelve,  eleven,  eight,  and  seven 
years.  The  calves  and  the  anterior  surface  of  the  thighs  are  h  ypertrophied.  The  muscles  of  the 
back  are  atrophied  The  eldest  has  so  much  weakness  of  the  muscles  of  the  neck  that  he  cannot 
hold  up  his  head.    (Curschmann,  Klin.  Abbilduugen.) 

connective  tissue  and  the  tleposition  of  fat  which  are  most  marked  in  the 
pseudohypertrophic  form  are  secondary  to  the  atrophy  of  the  muscle 
fibres.  The  giant  muscle  fibres  are  probably  an  attempt  at  compensa- 
tory hypertrophy. 

Symptomatology,  (a)  Landouzy-Dejerine  Type. — This  type  usually 
develops  in  early  childhood,  but  I  have  seen  two  ca.««es  develop  in  adult 
life.  The  peculiar  features  are  the  early  atrophy  affecting  the  muscles 
of  the  face  beginning  in  the  orbicularis  oris  and  extending  to  the  levator 
menti,  the  risorii,  and  later  to  the  other  muscles  of  the  face.    The  lips 


ABIOTBOPHIC  DISEASES 


921 


become  weak  and  cannot  be  firmly  closed,  the  mouth  is  held  open  with 
protruded  lips.  The  upper  face  muscles  usually  escape.  As  the  disease 
progresses  the  muscles  of  the  neck  and  shoulder  girdle  become  affected. 
There  are  no  fibrillary  tremors  of  the  muscles,  no  disturbance  of  sensa- 
tion, and  the  reaction  of  the  muscles  to  mechanical  and  electric  stimuli 
is  gradually  lost.  The  tendon  reflexes  diminish  with  the  loss  of  muscle 
power. 

Fig. 187 


Pseudohj'pertropliic  i>aial\>i».    Tlic  ;ici  ol  lising.    This  position  shows  the  weakness  of  the  muscles 
of  the  neck  and  the  atrophy  of  the  arms.     (Starr. ) 


Fig. 188 


Pseudohypertrophic  paralysis.    The  act  of  rising.    (Starr.) 


(6)  Erb's  juvenile  iijpe  usually  begins  between  the  twelfth  and  six- 
teenth year,  and  in  rare  instances  even  later.  The  muscles  of  the 
shoulder  o-irdle  are  first  affected.     The  pectoral  muscles,  the  trapezii, 


922 


DISEASES  OF  THE  NERVOUS  SYSTEM 

Fig. 189 


PseuUohypertropliic  paralysis.    The  act  ol  rising.     (Starr.) 
Fig. 190 


Pseudohypertrophic  paraly.sis.    Tlie  act  of  rising     (Starr.) 


PLATE  XXVII. 


Pseudohypertrophic  Paralysis. 


ABIOTBOPHIG  DISEASES 


923 


Fig. 191 


latissimus  dorsi,  rhomboids,  and  deltoids  are  successively  affected. 
There  may  be  a  true  atrophy  or  the  muscles  may  maintain  their  original 
size  or  even  be  slightly  increased  in  size,  but  v/ith  progressive  loss  of 
power.  There  is  difficulty  in  elevation  of  the  arms;  the  shoulders  are 
thrown  forward  and  the  scapula  project  away  from  the  chest;  and 
when  the  muscles  of  the  back  become  involved  lordosis  appears.  If 
there  is  no  arrest  of  the  disease  the  lower  extremities  become  affected 
beginning  in  the  muscles  of  the  hip  and  progressing  downward  to  the 
feet.  The  difficulty  in  walking  due  to  loss  of  power  in  the  lower  extrem- 
ities is  accentuated  by  the  affection  of  the  back  muscles,  until  finally 
the  patient  is  confined  to  the  wheeling  chair  or  to  bed. 

(c)  Pseudohypertrophic  Form. — This  form  usually  begins  early  in 
childhood  between  the  second  and  seventh  years  with  an  increase  in 
the  size  of  the  calves  of  the  legs  and  of  the 
thighs.  With  this  increase  in  size  there  is  a 
distinct  loss  of  power  with  a  clumsy  and  awk- 
ward gait  (Fig.  186).  Fatigue  develops  after 
slight  exertion  and  accentuates  the  awkward- 
ness and  weakness  of  the  lower  extremities. 
When  the  disease  is  fairly  well  advanced  the 
child  experiences  much  difficulty  in  arising 
from  a  sitting  or  recumbent  posture.  It 
soon  learns  to  use  the  hands  to  assist  it 
and  literally  climbs  up  itself  by  pushing 
with  the  hands  upward  along  the  leg  until 
it  assumes  an  erect  posture  (Figs.  187  to  190). 
W^hen  the  muscles  of  the  back  become  affected 
the  forward  curvature  of  the  spine  of  the 
lumbar  region  with  a  backward  position  of 
the  shoulders  and  cervical  spine  to  compensate 
for  this  gives  a  peculiar  standing  attitude 
(Fig.  191).  The  legs  are  held  wide  apart 
and  the  gait  is  described  at  this  period  as 
waddling.  The  muscles  of  the  shoulder  girdle 
and  arms  later  become  affected  and  present 
the  same  pseudohypertrophy  (Fig,  192).  The 
muscles  of  the  forearms  and  hands  if  affected 
at  all  are  only  so  in  the  very  latest  stages  of  the 
disease.  There  is  no  disturbance  of  sensa- 
tion. A  diminution  of  the  reflexes  occurs 
when  the  loss  of  power  becomes  marked.  The 
electric  reactions  here  are  normal,  but  there 
is  a  progressive  failure  even  to  increased 
quantities  of  the  galvanic  current.  The  disease 
may  become  arrested,  but  is  usually  slowly 
progressive  until  in  adult  life  some  intercurrent 
affection  causes  death.    (See  Plate  XXVII.) 

Prognosis. — Prognosis    as  far  as  life  is    con- 
cerned   is    altogether   favorable    in  all    these 


Pseudohypertrophic  paralysis. 
The  calves  are  large  ;  the  back  is 
weak  and  curved  forward.  Del- 
toids and  triceps  are  atrophied. 
Serrati  are  weak,  hence  the  scap- 
ulae protrude.    (Starr.) 


924 


DISEASES  OF  THE  NERVOUS  SYSTEM 


classes  of  cases.  In  advanced  cases  the  diaphragm  may  be  involved 
and  thus  lead  to  pneumonia,  tuberculosis,  or  other  respiratory  affections, 
or  the  patient  may  die  of  respiratory  paralysis.  Arrested  develop- 
ment occurs  in  a  small  number  of  cases  . 

Treatment. — The  treatment  of  all  forms  of  muscular  dystrophy  is 
practically  the  same.  It  is  better  for  children  to  live  as  much  as  possible 
in  the  open  air,  preferably  in  the  country.     The  nutrition  should  be 


Fig.  192 


Pseudohypertroptiic  paralysis ;  five  years  after  onset.    Muscles  of  arms  and  legs  greatly  hypertrophied. 
Both  feet  contractured  and  iu  a  position  of  talipes.   (Curschmann,  Klin.  Abbildungen.) 


good  and  the  exercise  carefully  regulated.  Well-directed  massage  and 
passive  and  resistive  movements  offer  the  best  methods  of  treatment. 
Fatigue  either  by  exercise  or  by  massage  should  be  carefully  avoided. 
Electricity  carefully  applied  in  moderate  quantities,  but  sufficient  to 
produce  contraction,  is  of  value.  In  the  cases  where  the  trunk  muscles  are 
early  affected  and  where  sufficient  power  for  locomotion  still  remains  in  the 
lower  extremity  light  braces  or  pla.ster-of-Paris  jackets  are  often  of  service. 


ABIOTBOPHIC  DISEASES 


925 


Fig.  193 


Peroneal  Type  of  Muscular  Atrophy.  (Charcot-Marie-Tooth  Dis- 
ease, j— This  disease  is  the  Progressive  Neural  INIuscular  Atrophy  of 
Hoffman,  and  was  long  considered  to  be  a  form  of  muscular  dystrophy 
affecting  the  lower  extremities,  but  in  1889  Hoffman  found  changes 
in  the  peripheral  nerves  sufficient  to  account  for  the  symptoms.  It  is 
therefore  not  a  muscular  dystrophy  in  the  strict  sense  of  the  term,  but 
a  degenerative  muscular  condition  secondary  to  changes  in  the  nerves. 

Etiology. — Heredity  seems  to  be  an 
important  factor.  It  also  occurs  as 
a  family  disease.  It  may  begin  at  a 
very  early  age  or  may  not  occur  until 
as  late  as  twenty.  Exposure  to  cold 
and  wet  has  been  given  as  an  etio- 
logical factor. 

Pathology.  —  The  pathological 
lesion  described  by  Hoffman  was  an 
atrophic  neuritis  in  the  peroneal 
nerves  and  with  degenerative  changes 
in  the  muscles  like  those  of  muscular 
dystrophy  (Fig.  193).  The  later  in- 
vestigations have  also  shown  slight 
sclerotic  changes  in  the  posterior 
columns  of  the  spinal  cord  and  in  the 
posterior  spinal  ganglia.  It  may, 
therefore,  be  considered  to  be  an 
affection  of  the  entire  peripheral  sen- 
sory path  with  a  peripheral  degenera- 
tive neuritis. 

Symptomatology.  —  The   lower   ex- 
tremities are  at  first  affected.    There 
progressive   loss    of   power    with 


IS 


atrophy  beginning  in  the  muscles  of 

the   feet    and    in    the   long  peroneal 

muscles  on  the  outer  side  of  the  leg. 

This  is  followed  by  an  involvement 

of     the     tibialis     anticus,      extensor 

communis    digitorum,  and    later    of 

the  calf  muscles.     This  results    after 

a  few  years  in  such  complete  loss  of 

power  as  to  incapacitate  the  sufferer 

from     either    standing   or     walking. 

The  development  of  toe-drop  and  the 

weakness    of  the  muscles  about    the 

knee    give    rise    to  a    peculiar    gait. 

The  foot  is  lifted  high  with  the  legs  held  wide  apart,  and  as  the  foot  is 

brought  down  the  foot  falls  outward.     The  muscles  are  the  seat  of 

fibrillary  contractions,  and  if  examined  by  the  galvanic  current  in  the 

early  stage  full  reactions  of  degeneration  may  be  obtained.     In  later 

stages  there  is  a  progressive  failure  to  react  to  either  faradic  or  galvanic 


Charcot-Marie-Tooth  disease.  Peroneal  atro- 
phy. Atrophy  of  the  legs  and  drop-feet,  and 
atrophy  of  the  hands.    (.Starr.) 


926  DISEASES  OF  THE  NERVOUS  SYSTEM 

current.  The  spindle-shaped  appearance  of  the  hnil)  is  (hie  to  the 
tlistril)ution  of  the  atrophy.  It  is  confined  to  areas  below  the  knee,  while 
the  thigh  muscles  remain  normal.  In  exceptional  cases  the  thif^h  muscles 
may  be  affected  and  occasionally  the  small  muscles  of  the  hand,  of  the 
forearm,  and  arm  may  be  later  involved.  In  unfavorable  cases  there  is 
progression  in  the  late  stages  to  the  muscles  of  the  trimk,  with  death 
from  some  intercurrent  affection. 

The  reflexes  in  the  affected  areas  are  lost  com])arativ(^ly  early  in  the 
disease.  There  may  be  loss  of  sensation  or  simple  diminution  along 
the  outer  side  of  the  legs. 

Prognosis. — Prognosis  for  life  is  good.  Prognosis  for  recovery  of 
function  is  unfavorable.  Some  cases  come  to  a  standstill  after  the 
affection  has  reached  the  knee.  In  other  cases  the  disease  extends  no 
farther  than  the  affection  of  the  lower  leg  and  the  forearm.  In  a  very 
small  number  of  cases  the  paralysis  may  extend  to  practically  all  the 
voluntary  muscles  of  the  body. 

Treatment. — The  treatment  shoidd  be  that  of  a  tonic,  stimulative 
character  with  attention  to  the  general  health  and  the  use  of  massage, 
graduated  movements,  electricity,  and  hydrotherapy. 


MALFORMATION  AND   IMPERFECT   DEVELOPMENT  OF  THE 

SPINAL  CORD. 

We  shall  not  consider  here  those  conditions,  such  as  the  entire  absence 
of  the  spinal  cord  or  of  the  posterior  spinal  ganglia,  which  are  merely  of 
a  scientific  interest  and  have  no  practical  bearing. 

Spina  Bifida. — This  is  a  frecjuent  condition  in  infanc-y  and  child- 
hood (Fig.  1!)4).  It  is  said  to  occur  in  one  case  out  of  every  thousand 
births. 

Etiology. — Inasmuch  as  the  spinal  arches  in  the  lumbar  cord  are  the 
last  to  close  any  interference  with  this  process  will  predispose  to  the  for- 
mation of  the  condition  under  consideration.  The  accunuilation  of  fluid 
in  the  meningeal  tumor  is  secondary  to  lack  of  resistance  and  does 
not  depend  either  upon  a  congenital  increase  of  fluid  or  increased 
secretion  of  cerebrospinal  fluid. 

Pathology. — The  careful  study  of  the  spine  of  large  numbers  of  chil- 
dren will  reveal  at  times  evidence  of  defective  development  of  the  spinal 
arch€\s.  In  the  simplest  form  it  may  be  merely  an  absence  of  the  spinous 
process  of  a  single  vertebra.  In  others  there  appears  to  be  a  diminution 
in  size  of  the  vertebne  and  a  failure  of  the  laminjie.  In  still  others  there 
is  an  entire  absence  of  the  bony  structures  closing  the  spinal  canal 
either  of  a  single  or  of  several  vertebme.  When  several  vertebra  are 
deficient  a  protrusion  of  the  membranes  of  the  cord  filled  by 
cerebrospinal  fluid  takes  place.  This  condition  is  spoken  of  as  meningo- 
cele. The  wall  of  the  sac  is  lined  by  the  arachnoid  but  not  always  by 
the  dura.  This  latter  may  be  congenitally  absent  over  the  tumor.  The 
entire  structure  is  covered  by  the  skin. 


ABIOTBOPHIO  DISEASES 


927 


In  the  more  complicated  cases  the  lower  portion  of  the  spinal  cord 
protrudes  into  this  sac  and  with  it  the  nerve  roots  (meningomyelocele). 
In  still  other  cases  the  lower  portion  of  the  cord  is  extended  to  form  a 
cavity  and  this  is  enclosed  within  the  meningeal  sac  (syringomyelocele). 
A  considerable  accumulation  of  connective  tissue  and  fat  may  be  present 
(Fig.  195). 

Symptomatology. — Simple  meningocele  without  involvement  of  the 
spinal  cord  may  be  associated  with  very  few  symptoms.  As  a  rule, 
however,  there  ai'e  other  congenital  defects,  such  as  club-feet,  ectopia  of 
the  bladder  or  other  viscera,  hydrocephalus,  etc. 


Fig. 194 


Spina  bifida. 

When  the  spinal  cord  is  included  in  the  sac  the  motor  and  trophic 
functions  may  be  disturbed.  There  may  be  spastic  or  flaccid  paralysis 
with  atrophy,  anesthesia,  disturbance  of  bladder  or  rectal  function, 
depending  upon  the  degree  of  involvement  of  the  cord.  The  pressure 
from  an  increased  amount  of  fluid  may  be  a  factor  in  the  production  of 
these  symptoms. 

The  physical  and  mental  development  of  the  child  is  backward 
and  poor;  the  nutrition  weak  and  easily  disturbed.  The  skin  cover- 
ing the  fluctuating  tumor  may  be  perfectly  normal  or  may  be  very 
thin,  due  to  pressure. 


928 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Fig.  195 


Diagnosis. — The  diagnosis  is  usually  easy.  I  have,  however,  seen  a 
lipoma  of  soft  consistence  directly  over  the  spine  mistaken  for  a  meningo- 
cele. The  j)r(\sence  of  a  bony  lamina  beneath  and  the  absence  of  true 
fluctuation  made  the  diagnosis.  In  doubtful  cases  hypodermic  punc- 
ture and  the  presence  of  cerebrospinal  fluiil  with  its  distinctive  micro- 
scopic and  chemical  qualities  will  separate  the  cyst  of  a  spina  bifida 

from  that  due  to  other  conditions. 
The  a'-rays  may  also  be  used  to 
determine  the  absence  of  bone. 

Prognosis. — Not  infre(|uently  the 
sac  ru|)tures  during  or  shortly  after 
birth,  with  a  fatal  result.  Se[)tic 
infection  from  ulceration  or  the  skin 
overlying  the  tumor  with  the  pro- 
duction of  meningitis  is  very  likely 
to  occur.  In  simj)le  meningocele 
without  involvement  of  the  spinal 
tissues  prognosis  is  altogether  favor- 
able as  far  as  life  is  concerned. 
This  area,  however,  must  aways  be 
carefully  ])rotected  to  prevent  septic 
infection.  In  meningomyelocele 
and  syringomyelocele  prognosis  is 
unfavorable. 

Treatment. — Apart  from  the  gen- 
eral care  of  the  child's  health  and 
the  protection  of  the  tumor  from  in- 
jury the  treatment  is  entirely  surgical. 
The  surgical  procedure  depends  on 
the  morphology  of  the  tumor.  In 
some  cases  a  meningocele  represents 
a  tru<.'  type  of  sacculated  hernia  of 
the  meninges  in  which  a  large  sac 
communicates  by  a  small  opening 
with  the  spinal  canal.  In  such  cases 
a  ligature  may  l)e  applicfl  and  the 
sac  cut  away.  In  other  cases  where 
there  is  free  communication,  more 
extensive  surgical  procedures  with 
closiu-e  of  the  spinal  canal  may  be 
attempted.  In  any  event  the  opera- 
tion is  a  serious  one  and  should  not 
be  undertaken  wh(>re  there  is  extensive  hydrocephalus  or  evidence  of 
complete  destruction  of  cord  function.  Operation  should  not  be  at- 
tempted until  some  time  after  birth  (at  least  several  months)  and  only 
when  the  physical  condition  of  the  child  warrants  such  a  serious  pro- 
cedure. 


Case  of  syriDgomyelia.  Atrophy  of  the 
muscles  of  the  shoulders  and  right  arm. 
Curvature  of  the  spine  forward  from  atrophy 
of  muscles  of  the  back.    (Starr.) 


CHAPTER  XXXVII. 

DISEASES  OF  THE  BRAIN  AND  MENINGES. 
MENINGITIS. 

Inflammations  of  the  membranes  of  the  brain  may  be  acute,  sub- 
acute, or  chronic.  They  may  be  localized  to  the  brain  alone,  the  spinal 
cord,  or  may  affect  both.  Meningeal  affections  are  especially  frequent 
in  infancy  and  there  is  a  special  form  described  by  Gee  and  Barlow  to 
which  the  term  non-tuberculous  leptomeningitis  infantum  has  been 
given.  Koplik  and  others  have  considered  many  of  these  cases  to  be 
infantile  types  of  epidemic  cerebrospinal  meningitis. 

Etiology. — In  the  majority  of  cases  inflammation  may  be  traced  to  an 
infection  of  the  meninges  by  some  pathogenic  organism.  It  most  fre- 
quently occurs  in  association  with  the  acute  infectious  fevers.  Pneu- 
monia, erysipelas,  septicemia,  and  tuberculosis  are  the  most  frequent 
causes.  It  is,  however,  found  in  association  with  or  following  typhoid 
fever,  smallpox,  scarlet  fever,  measles,  diphtheria,  influenza,  and  rarely 
with  rheumatism  and  mumps.  A  chronic  inflammatory  condition  of 
the  meninges  is  met  with  in  tuberculosis  and  syphilis.  Traumatism 
with  or  without  an  involvement  of  the  meninges  may  be  followed  by 
meningitis.  It  occurs  by  extension  from  neighboring  inflammatory 
processes  and  especially  from  mastoid  disease  and  disease  of  the  middle 
ear.  Inflammatory  processes  in  the  nose  may  extend  to  the  brain. 
Infection  may  also  take  place  from  suppurative  conditions  of  the  sinuses 
or  may  be  transmitted  to  the  meninges  by  operative  procedures  on  the 
sinuses.  Septic  emboli  or  blood  infections  from  pus  accumulations 
elsewhere  in  the  body  and  especially  those  due  to  bone  disease  not  infre- 
quently infect  the  meninges.  A  special  form  of  meningitis,  the  epidemic 
cerebrospinal  meningitis,  is  due  to  the  diplococcus  intracellularis  of 
Weichselbaum.  A  study  of  the  causes  of  meningitis  will  reveal  that 
the  disease  is  due  either  to  the  infection  of  the  cerebral  membranes 
by  the  specific  organism  causing  the  disease  with  which  it  is  associated 
or  to  a  mixed  infection  with  some  septic  process  such  as  occurs  in  tuber- 
culosis. We  may  therefore  have  in  such  cases  a  type  of  inflammation 
characteristic  of  the  causative  agent,  such  as  tuberculous  meningitis, 
entirely  different  from  that  due  to  the  mixed  infection — i.  e.,  the  septic 
meningitis.  The  most  common  organism  found  in  the  septic  type  of 
meningitis  is  a  streptococcus  or  a  staphylococcus,  although  any  of  the 
pyogenic  organisms  may  be  found. 

Pathology. — In  acute  meningitis  the  inflammation  is  localized  to  the 
soft  membranes  of  the  brain  and  especially  to  the  pia  mater  in  direct 
59  ( 929 ) 


930  DISEASES  OF  THE  NERVOUS  SYSTEM 

contact  witli  the  l)rain  substance.  While  the  pia  mater  eoverhig  the 
entire  hraiii  is  usually  more  or  less  involved  there  is  a  tendency  in  cer- 
tain forms  of  meniuiritis  to  a  localization  in  certain  definite  areas. 
Thus  in  the  septic  processes  extending  from  middle-ear  disease  the 
inflammation  may  be  found  only  on  one  side  of  the  brain  or  even  local- 
ized to  a  small  area.  In  septic  meningitis  in  the  great  majority  of  cases, 
whether  primary  or  secondary  to  other  processes  or  infections,  the 
convexity  of  the  brain  is  more  likely  to  be  infected  than  the  base;  whereas 
in  the  epidemic  form,  while  the  entire  brain  and  spinal  cord  may  be 
affected,  the  part  most  involved,  as  a  rule,  is  the  base.  In  the  meningitis 
of  infancy  described  by  Gee  and  Barlow  the  process  is  localized  to  the 
posterior  portion  of  the  base  of  the  brain.  Tuberculous  meningitis 
elects  the  base  of  the  brain,  and  especially  the  anterior  part  near  the 
optic  commissure. 

Inflammatory  conditions  of  the  meninges  do  not  differ  in  their  path- 
ology from  that  seen  in  other  serous  membranes.  We  may  divide  the 
pathological  manifestations  into  three  stages:  (1)  a  stage  of  congestion, 
(2)  a  stage  of  effusion,  and  (3)  a  chronic  adhesive  stage.  The  effusion 
may  be  either  serous  in  type  or  if  the  infecting  agent  be  a  pyogenic 
organism  there  is  an  accumulation  of  pus. 

Stage  of  Cnngcsfion. — There  is  a  marked  hyperemia  affecting  the  pia 
mater  shortly  followed  by  an  exudation  of  serum,  lymph,  fil)rin,  and 
a  few  leukocytes.  The  surface  of  the  brain  appears  a  bright  red,  and 
on  close  examination  the  membranes  have  lost  their  smooth,  shining 
ap])earance  and  are  dull  and  roughened.  In  passing  the  finger 
lightly  over  the  inflamed  areas  a  decidedly  roughened,  adhesive  feeling 
will  be  imparted.  The  microscopic  examination  at  this  stage  shows  a 
marked  distention  of  the  capillaries,  an  extravasation  of  red  corpuscles 
here  and  there,  a  film  of  fibrin  on  the  surface  of  the  brain,  and 
an  accunudation  of  small  round  cells  around  the  bloodvessels  and 
free  in  the  meshes  of  the  pia  and  arachnoid.  This  process  is  not 
confined  to  the  meninges,  but  may  be  followed  in  marked  cases  by  a 
similar  change  along  the  bloodvessels,  extending  from  the  pia  into  the 
brain  cortex.  The  inflammatory  process  may  stop  at  this  congestive 
stage  with  little  damage  to  the  cerebral  tissues.  When  the  meningitis 
afl'ects  the  base,  however,  even  a  dry  meningitis  of  this  grade  may  cause 
serious  damage  to  the  cranial  nerves.  This  is  especially  true  of  the 
nerves  of  special  sense,  the  auditory  and  optic  nerves.  In  cases  where 
the  entire  pia  mater  is  involved  the  same  changes  are  found  in 
the  extension  of  the  pia  into  the  brain  ventricles — i.  e.,  in  the  choroid 
plexus. 

Stage  uf  Effnsion. — In  inflammatory  conditions  at  the  base  of  the 
brain  obstruction  of  the  communication  between  the  ventricles  and 
the  subarachnoid  space  by  the  inflanniiatory  exudate  may  occur  and 
two  closed  sacs  are  formed;  one  an  internal  closed  area  comprising  the 
ventricles,  the  other  the  subarachnoid  spaces.  Even  when  obstruction 
does  not  take  place  the  accunmlation  of  fluid  may  be  very  extensive  and 
cause  serious  pressure  on  the  brain.     In  septic  processes  the  convexity 


DISEASES   OF  THE  BRAIN  93I 

and  base  of  the  brain  may  be  bathed  in  pus.  In  those  cases  where  the 
ventricles  are  closed  the  accumulation  of  fluid  produces  a  condition  of 
internal  hydrocephalus.  The  ventricles  are  markedly  distended  and 
in  the  case  of  infants  the  pressure  is  sufficiently  great  to  cause  a 
separation  of  the  sutures  and  produce  a  globular  enlargement  of  the 
head. 

A  purulent  process  of  the  meninges  extends  along  the  bloodvessels 
into  the  brain  substance,  and  is  followed  either  by  an  inflammation  of 
the  cortex  by  extension  or  small  abscesses. 

Chronic.  Adhesive  Stage. — In  cases  of  intense  inflammation  in  which 
the  plastic  exudate  is  extensive  adhesions  between  the  membranes  of 
the  brain  may  occur.  They  are  more  frequently  seen  at  the  base  of  the 
brain  and  by  involvement  of  the  cranial  nerves  produce  serious  sequelae. 
The  organization  and  contraction  of  the  exudate  give  rise  to  such 
pressure  upon  the  cranial  nerves  as  to  cause  partial  or  complete  degen- 
eration. The  previous  inflammatory  condition  of  the  nerve  tissues  by 
extension  from  the  meningeal  involvement  is  also  a  marked  factor  in 
this  degeneration  of  the  cranial  nerves  following  meningitis.  If  com- 
plete obstruction  of  the  aqueduct  of  Sylvius  or  the  foramina  at  the 
base  of  the  brain  connecting  the  ventricles  with  the  subarachnoid  spaces 
takes  place,  either  from  the  inflammatory  process  or  as  a  result  of  sec- 
ondary adhesions,  a  chronic  hydrocephalus  is  produced.     (See  p.  967.) 

Symptomatology. — The  symptoms  of  meningitis  will  depend  upon 
the  intensity  of  the  septic  process  and  the  age  at  which  the  child  is 
affected.  In  infants  the  symptoms  develop  suddenly  with  high  fever, 
although  the  temperature  in  some  cases  may  vary  only  between  100° 
and  101°  F.  The  early  symptoms  will  be  those  due  to  the  intense  con- 
gestion and  inflammation  of  the  first  stage.  As  early  as  the  second  day 
there  is  evidence  of  marked  pain,  referred  to  the  head;  there  may  be 
tenderness  over  the  scalp,  marked  irritability,  and  disturbed  sleep. 
The  child  buries  its  head  in  the  pillow;  there  is  retraction  of  the  head; 
stiffness  of  the  muscles  at  the  back  of  the  neck;  photophobia,  and  in- 
creased sensitiveness  to  even  slight  sound.  Vomiting  may  occur  early, 
and  usually  by  the  third  or  fourth  day  the  restlessness  and  twitchings 
of  the  muscles  are  followed  by  convulsions.  The  symptoms  may  subside 
here  without  loss  of  consciousness,  or  more  frequently  go  on  to  the 
second  stage,  when  evidence  of  hydrocephalus  occurs  and  death  super- 
venes. A  case  following  this  type  will  run  its  course  in  from  six  to  eight 
days. 

Besides  this  septic  type  of  meningitis  with  a  rapid  involvement  of 
the  entire  meninges,  there  is  a  class  of  cases  in  which  the  intensity  of 
the  infection  and  the  resulting  pathological  process  is  much  less  marked 
than  that  above  described.  Here  again  the  disease  may  come  on  sud- 
denly with  a  chill  or  even  a  convulsion,  but  the  fever  is  not  so  high 
and  the  disease  runs  a  much  longer  and  milder  course.  The  process 
is  not  general,  but  localized  to  some  one  portion  of  the  brain.  In  one  of 
the  cases  reported  by  Gee  and  Barlow  the  process  was  so  slight  as  to 
result  only  in  a  congestion,  with  dulling  of  the  lustre  of  the  meninges. 


932  DISEASES  OF  THE  NERVOUS  SYSTEM 

There  mav  be  even  in  some  cases  running  a  mild  course  distinct  pus 
formation.  When  the  meningitis  affects  the  vertex  (the  convexity  of 
the  brain)  the  manifestations  are  entirely  different  from  those  in  which 
the  base  is  affected.  The  anterior  part  of  the  convexity  is  more  likely 
to  be  affected  than  the  posterior.  The  symptoms  produced  may  be 
very  mild,  and  easily  overlooked  on  account  of  association  with  the 
infectious  fevers.  There  is  some  headache  and  vomiting.  Retraction 
of  the  head,  if  it  occurs  at  all,  is  only  slight  and  has  to  be  carefully  looked 
for.  Convulsions  sometimes  occur  and  may  be  partial  and  localized  to 
one  or  more  parts  of  the  body,  but  may  later  become  general.  General 
epileptiform  convulsions  may  be  very  severe,  frequently  repeated, 
and  associated  with  high  temperature.  The  spasms  are  usually  clonic 
in  type  and  lead  to  marked  exhaustion.  There  is,  as  a  rule,  no  tonic 
contracture  of  the  extremities,  and  while  Kernig's  sign  is  usually  present 
it  mav  in  rare  cases  be  absent.  There  may  be  an  associated  inflamma- 
tion of  the  meninges  surrounding  the  spinal  cord.  There  will  then  be 
evidence  of  pain  and  tenderness  along  the  spine,  hyperesthesia  of  the 
skin  of  the  trunk  and  of  the  extremities,  individual  muscular  twitchings, 
and  varving  paralyses  affecting  one  or  all  of  the  extremities. 

Posterior  Basic  Meningitis. — This  is  a  localized  meningitis  of  the  base 
of  the  brain.  The  primary  seat  of  the  inflammation  is  in  the  area  of 
junction  of  the  brain  and  spinal  cord  where  the  cerebellum  overlaps 
the  medulla.  From  here  it  extends  forward  along  the  transverse  fissure 
into  the  ventricles  or  along  the  base  of  the  brain  as  far  as  the  optic 
commissure,  involving  the  inferior  surface  of  the  temporosphenoidal 
lobes,  and  may  extend  downward  along  the  upper  portion  of  the  spinal 
cord.  The  convexity  of  the  brain  is  usually  not  affected,  or  at  the  most 
onlv  verv  slightly.  While  the  process  is  usually  of  a  plastic,  fibrinous 
character  it  may  go  on  in  severe  cases  to  suppuration.  In  cases  that 
recover  chronic  adhesions  may  unite  the  cerebellum  to  the  medulla, 
obstruct  the  commiuiication  of  the  ventricles  with  the  subarachnoid 
space,  or,  by  closing  the  aqueduct  of  Sylvius,  lead  to  chronic  hydro- 
cephalus. The  accumulation  found  at  autopsy  in  the  ventricles  of  these 
cases  is  opacjue,  due  to  large  flakes  of  inflammatory  lymph,  or  even  pus, 
with  high  specific  gravity — in  other  words,  of  inflammatory  origin. 
Koplik  anfl  others  have  recently  reported  the  finding  of  the  diplococcus 
of  epidemic  cerebrospinal  meningitis  in  some  cases  of  this  type  of  menin- 
gitis occurring  during  an  epidemic.  The  diplococci  were  present  both 
in  the  cerebrospinal  fluid  and  in  the  exudate.  There  is  no  doubt  that  a 
certain  group  of  cases  of  epidemic  cerebrospinal  meningitis  in  infancy 
presents  the  clinical  picture  of  posterior  basic  meningitis.  I  do  not 
believe  that  all  cases  of  posterior  basic  meningitis  are  due  to  the  diplo- 
coccus of  Weichselbaum.  The  clinical  type  is  sufficiently  distinct  to 
warrant  separate  consideration. 

Symptomatology. — The  symptoms  develop  suddenly  in  the  mild  cases 
and  run  a  long  course  of  from  four  to  six  weeks;  the  temperature  is  not 
very  high,  ranging,  as  a  rule,  from  98°  to  102°  F;  in  some  cases  it  may 
not  be  above  100°,  or  at  the  most  101°  F.     But  even  in  the  subacute  mild 


DISEASES  OF  THE  BRAIN  933 

eases  terminal  hyperpyrexia  even  as  high  as  107°  or  108°  F.  may  occur;  in 
other  cases  a  subnormal  temperature  develops  as  death  approaches. 
The  most  important  and  persistent  symptom  is  retraction  of  the  head; 
the  rigidity  of  the  neck  muscles  may  go  on  to  opisthotonos.  Vomiting  is 
frequent  and  may  be  the  first  symptom.  Nystagmus  due  to  cerebellar 
cortical  irritation  is  frequent ;  strabismus  is  common.  The  pupils  in 
the  early  stage  are  contracted  and  later  become  irregular  and  markedly 
dilated.  Examination  of  the  eye-grounds  reveals  optic  neuritis  only  in 
a  small  number  of  cases,  but  this  in  itself  is  of  value  in  differentiating 
this  form  of  meningitis  from  tuberculous  meningitis,  which  also  affects 
the  base  and  is  of  much  more  frequent  occurrence.  Blindness,  transient 
in  character,  may  occur  without  changes  in  the  optic  nerve  and  is  prob- 
ably due  to  interference  with  the  optic  paths  in  the  neighborhood  of 
the  optic  thalamus.  In  the  early  stages  there  is  considerable  restlessness 
and  irritation,  followed  in  severe  cases  by  torpor  and  coma.  Convul- 
sions are  rare,  but  it  is  not  infrequent  to  find  in  severe  cases  a  marked 
condition  of  persistent  tonic  spasm  of  the  extremities.  In  such  cases 
the  clinical  picture  is  typical ;  the  head  is  retracted,  the  arms  are  extended 
and  rigid,  the  hands  flexed  and  held  outward,  and  the  lower  extremities  in 
marked  extension.  The  spasm  in  some  cases  may  be  flexor  in  type,  with 
the  body  bent  forward,  the  head  in  extreme  retraction,  and  the  legs  and 
arms  fixed  in  a  semiflexed  position.  If  the  child  be  conscious  attempts 
to  reduce  this  spasm  by  changing  the  position  of  the  limbs  or  reducing 
the  retraction  of  the  head  leads  to  considerable  pain  and  irritation. 

Diagnosis. — The  ease  with  which  a  diagnosis  is  made  in  a  case  of 
meningitis  will  depend  mainly  upon  the  time  at  which  the  case  is  seen. 
In  well-developed  cases  the  diagnosis  is  comparatively  easy.  In  mild 
cases  there  is  more  difficulty.  In  the  former  the  presence  of  a  source  of 
infection,  with  fever,  somnolence,  coma,  inequality  of  the  pupils,  straVjis- 
mus,  nystagmus,  and  retraction  of  the  head,  gives  a  distinct  clinical 
picture.  The  greatest  difficulty  in  diagnosis  is  met  with  in  rather  a 
large  class  of  cases  in  which  symptoms  very  closely  resembling  menin- 
gitis are  due  to  toxic  irritation  of  the  central  nervous  system.  The 
French  clinicians  have  enabled  us  to  disguise  our  ignorance  of  the  real 
nature  of  this  affection  under  the  term  meningismus.  At  the  beginning 
or  during  the  course  of  or  in  convalescence  from  various  infections, 
especially  pneumonia,  influenza,  typhoid,  the  summer  diarrheas, 
reflexly  from  dentition  or  from  the  retained  toxins  due  to  poorly  drained 
joint  suppurations,  a  series  of  symptoms  develop  which  resemble  very 
closely  those  present  in  meningitis  and  are  often  identical  with  them. 
It  may  be  stated  that  in  some  cases  a  clinical  picture  is  presented 
that  cannot  be  differentiated  from  simple  meningitis  and  yet  at  autopsy 
no  trace  of  an  inflammatory  condition  of  the  meninges  can  be  found. 
This  is  especially  true  in  the  forms  of  meningismus  observed  during 
the  course  of  the  intestinal  infections.  In  older  children  where  the 
Babinski  reflex  is  of  value— f.  e.,  where  the  normal  plantar  reflex  is 
flexion — extension  of  the  toes  to  plantar  irritation  and  the  presence  of 
Kernig's  symptom  will  assist  in  differentiating  the  true  from  the  false 


934  DISEASES  OF  THE  NERVOUS  SYSTEM 

form  of  moninpjitis.  In  pneumonia  the  eerel)ral  manifestations  may 
occur  early,  before  the  lini<i^coii(Hti()n  can  he  locahzcuh  The  convulsions, 
the  delirium,  and  the  agitation  diminish  as  the  j)ulm()narv  symptoms 
increase  and  the  evidence  of  an  increa^se  in  the  inflammatory  symptoms 
which  would  cause  a  paralytic  condition  of  the  cranial  nerv(>s  and  the 
extremities  does  not  occur.  The  variations  in  the  symptoms  followiui:; 
closely  those  due  to  the  pulmonary  disease  should  also  point  to  a 
spiu'ious  form  of  meningitis.  In  the  lobar  type  of  pneumonia  the  cere- 
bral symptoms  diminish  and  rapidly  disappear  after  the  crisis.  In 
typhoid  the  cerebral  symptoms  coincide  with  the  intensity  of  the  typhoid 
intoxication  and  here  again  disappear  as  this  condition  improves.  In 
dentition  and  reflex  disturbances  due  to  intestinal  parasites  the  removal 
of  the  causative  factor  is  followed  ])y  a  disappearance  of  the  symptoms. 
The  absence  of  fever  and  reflex  conditions  is  an  important  aid  in  diag- 
nosis. In  older  children  the  presence  of  hysteria  must  be  taken  into 
consideration  in  diagnosis,  but  the  absence  of  fever,  the  variation  of  the 
course  of  the  disease,  the  bizai're  character  of  the  convulsions,  the  ty})i(al 
disturbance  of  sensation,  and  the  control  of  the  symptoms  by  suggestion, 
will  easily  differentiate  the  two  conditions. 

Retraction  of  the  head,  intense  headache,  vomiting,  vertigo,  convul- 
sions, and  optic  neuritis  may  l)e  present  in  cases  of  brain  iinnor  aflecting 
the  cerebellum  and  may  be  mistaken  for  meningitis.  The  development, 
however,  is  slow  and  progressive;  there  is  an  absence  of  fever  and  of 
knee-jerks,  a  marked  ataxia  of  the  gait,  and  the  optic  neuritis  is  nmch 
more  marked  and  present  in  a  much  larger  numl)er  of  cases  than  in 
meningitis.  In  meningeal  hemorrJiage  the  onset  is  sudden  with  little 
fever,  and  the  convulsions  are  verv  violent.  The  following  case  is  an 
example  of  meningeal  symptoms  (meningismus)  due  to  retained  pus. 

M.  \j.,  aged  six  years,  suffering  from  a  suppurating  hip-joint  disease 
developed  fever  varying  from  101°  to  103°  F.,  with  loss  of  apj^etite,  rest- 
lessness, rigidity  of  the  muscles  of  the  neck,  and  marked  retraction  of 
the  head.  There  was  no  paralysis  nor  convulsions;  the  child  was  very  sick 
and  grew  rapidly  worse.  The  dressings  which  had  been  applied  by  the 
nurse  were  negligently  and  irregularly  done.  A  diagnosis  of  meningitis 
was  made  by  the  surgeon  in  attendance,  but  the  slow  onset,  the  absence 
of  paralytic  symptoms,  the  absence  of  convulsions,  flexion  of  the  toes 
to  plantar  irritation,  the  absence  of  Kernig's  symptom  led  to  a  diagnosis 
of  meningismus  from  retained  pus.  A  thorough  cleansing  of  the  sinuses 
about  the  hip-joint,  with  proper  attention  to  the  frecpient  renewal  of 
tlressings,  resulted  in  a  ra])id  disappearance  of  the  symptoms  in  two  or 
three  days. 

The  differential  diagnosis  from  the  epidemic  form  of  cerebrospinal 
meningitis  and  from  tuberculous  meningitis  will  be  considered  under 
those  headings.  ^Fhis  diagnosis  rests  mainly  on  the  examination  of  the 
cerebrospinal  fluid  obtained  by  lumbar  puncture  and  in  all  cases  of 
doul)tful  diagnosis  ])ositive  results  as  to  the  cause  of  the  disease  may 
be  obtained  by  a  microscopic  and  baeteriologic  studv  of  the  cerebro- 
spinal fluid.     (See  p.  382.) 


DISEASES  OF  THE  BRAIN  935 

Prognosis. — The  duration  of  cases  of  posterior  meningitis  is,  as  a  rule, 
much  longer  even  in  fatal  cases  than  either  of  the  forms  above  described. 
The  usual  duration  is  from  six  to  eight  weeks,  although  minor  symptoms 
with  slight  fever  in  favorable  cases  may  persist  for  two  or  even  three 
months.  Hydrocephalus  is  a  very  frequent  sequel.  Deafness  and 
blindness  are  not  of  such  frequent  occurrence  in  cases  which  recover 
from  this  form  as  in  other  forms  of  meningitis.  The  prognosis  is  also 
more  favoral^le,  which  is,  however,  saying  but  little  for  the  hope  of 
recovery  in  the  large  majority  of  cases. 

The  clinical  picture  of  all  the  above  forms  of  meningitis  varies  with 
the  period  of  life  in  "vVhich  it  develops.  In  late  childhood  going  on  to 
adult  life  the  clinical  picture  approaches  that  seen  in  the  adult.  The 
onset  is  not,  as  a  rule,  so  sudden  and  there  may  be  prodromal  symptoms 
of  headache,  malaise,  irritability,  etc.  When  the  headache  becomes 
more  intense  fever  develops,  the  pulse  becomes  slowed ;  there  is  marked 
constipation,  irritability  to  light  and  sound  impressions,  and  evidence 
of  irritation  of  the  motor  cortex.  Slowness  of  the  pulse  and  the  consti- 
pation are  not  met  with  in  infants,  and  when  they  occur  in  childhood 
are  valuable  early  signs.  After  several  days  stupor  develops  and  is 
followed  at  varvino;  times  in  different  cases  bv  coma.  The  convulsions 
of  the  early  stage  are  followed  by  a  paretic  or  paralytic  condition  of  the 
extremities.  Trismus  and  grinding  of  the  teeth  are  followed  by  dropping 
of  the  jaw.  The  eye  symptoms  do  not  differ  from  those  above  detailed 
in  the  early  forms.  In  the  later  stages  the  pulse  becomes  very  rapid, 
the  fever  becomes  higher,  and  death  occurs.  In  the  growing  child  and 
the  adult  the  pressure  symptoms  in  the  stage  of  hydrocephalus  are 
more  marked  than  in  the  infant  on  account  of  the  unyielding  character 
of  the  skull.  The  prognosis  as  adult  life  is  approached  is  somewhat 
better  than  in  childhood. 

Treatment. — The  treatment  of  meningitis  is  mainly  symptomatic. 
Any  possible  source  of  infection,  such  as  suppuration  of  the  middle  ear 
or  of  the  mastoid  or  accumulations  of  pus  elsewhere  in  the  body,  should 
be  carefully  treated.  In  infectious  fevers  in  which  meningitis  is  a  fre- 
quent complication,  the  ear  and  the  nasal  cavities  should  be  kept  as 
clean  as  possible  and  where  skin  lesions  are  present  they  should  also 
receive  careful  attention.  The  child  should  be  placed  in  a  quiet  room 
and  protected  from  all  possible  sources  of  irritation.  If  the  temperature 
is  high  it  should  be  controlled  by  hydrotherapy.  An  ice-cap  to  the 
head  will  assist  in  controlling  the  pain;  a  cold  pack  will  very  often 
relieve  the  agitation  and  irritability  and  assist  in  reducing  the  tem- 
perature. If  constipation  be  present  or  even  without  this,  calomel  in 
divided  doses  has  a  beneficial  effect  early  in  the  disease.  This  may 
be  followed  by  an  occasional  saline  purge  later  in  the  disease,  with 
the  idea  of  decreasing  the  congestion.  Lumbar  puncture  may  give  in 
some  cases  considerable  cloudy  fluid  with  a  diminution  of  pressure 
symptoms  and  as  a  therapeutic  measure  it  occasionally  gives  excellent 
results;  more  often,  and  especially  where  the  communication  between 
the  ventricles  and  the  subarachnoid  space  is  blocked  by  plastic  lymph 


936  DISEASES  OF  THE  NERVOUS  SYSTEM 

or  adhesions,  the  symptoms  of  pressure  persist  in  spite  of  the  operation. 
Operative  procechires,  such  as  trcphiniiifi;  and  (h'aina<jje,  (h'ainage  of  the 
fourth  ventricle  after  trephining  the  occipital  bone,  tapping  the  lateral 
ventricles  through  the  anterior  fontanel,  etc.,  have  all  been  attempted 
in  a  very  small  number  of  cases,  but  the  residts  are  unsatisfactory  on 
account  of  the  failure  of  children  to  react  from  the  shock  of  the  opera- 
tion. They  cannot  therefore  be  recommended  as  routine  pi'ocedures 
in  this  disease. 

Lees  and  Barlow  speak  highly  of  the  effect  of  paracentesis  of  the 
tympanic  membranes  where  any  suspicion  of  ear  disease  is  present. 
They  have  also  secured  results  from  the  use  of  potassium  iodide  in 
doses  of  0.()()5  to  0.195  gm.  (1  to  3  gr.)  every  two  hours  even  in  in- 
fants. Mercury  in  the  form  of  mercury  and  chalk,  0.065  gm.  (1  gr.), 
three  times  a  day  or  by  the  inunction  of  1.95  gm.  (^  dr.)  of  mercurial 
ointment  daily,  may  be  used.  Excepting  cases  where  there  is  distinct 
evidence  of  syphilis  I  have  seen  no  results  from  the  use  of  these  drugs. 
Cases  which  recover  are  usually  treated  by  careful  attention  to  the  general 
nutrition  and  to  meeting  individual  symptoms  by  simple  measures. 

The  tul)erculous  form  of  meningitis  and  the  epidemic  cerebrospinal 
type  are  to  be  found  in  their  respective  sections. 


ENCEPHALITIS. 

Encephalitis  is  an  inflammation  of  the  cerebral  tissues  non-purulent 
in  character.  Acute  localized  inflammation  of  the  cerebral  tissues 
occurs  more  frequently  in  childhood  than  at  any  other  time  of  life. 
This  is  undoubtedly  due  to  the  influences  of  the  acute  infections  acting 
as  ])redisposing  factors. 

Etiology. — P^ncephalitis  occurs  during  the  course  of  or  as  a  sequel 
to  the  following  acute  infections:  influenza,  scarlet  fever,  measles, 
diphtheria,  pertussis,  pneumonia,  mumps,  erysipelas,  ulcerative  endo- 
carditis and  other  septicemic  conditions.  Ptomaine  poisoning  (from 
both  fish  and  meat)  and  carbon  dioxide  intoxication  are  also  factors. 

Pathology. — Acute  non-suppurative  inflammations  have  been  described 
in  the  preceding  pages:  in  the  peripheral  nerves,  as  localized  parenchy- 
matous and  interstitial  neuritis,  in  the  gray  matter  of  the  anterior  horns 
of  the  spinal  cord,  in  infantile  spinal  paralysis,  and  in  the  posterior 
spinal  ganglia  in  herpes  zoster.  The  pathological  process  does  not 
differ  essentially  in  any  of  the  three  conditions.  There  is  a  central  zone 
of  intense  congestion  with  hemorrhagic  extravasation,  perivascular 
round-cell  accumulation,  and  destruction  of  nerve  tissue.  About  this 
area  there  is  a  zone  of  congestion.  Secondary  degeneration  in  the 
nerve  elements  affected  follows  and  its  distribution  depends  on  the 
areas  involved.  When  the  acute  inflammation  subsides  cicatricial 
tissue  is  found  in  the  area  of  destruction  of  nerve  tissue.  While  any 
part  of  the  encephalon  may  be  affected  there  are  certain  areas  of  elec- 
tion.    In  the  cortex  the  motor  area  is  most  frequently  involved.     The 


DISEASES   OF  THE  BBAIN  937 

gray  matter  surrounding  the  aqueduct  of  Sylvius  is  the  seat  of  that 
form  called  the  polioencephalitis  superior  of  Wernicke.  The  cells  of 
the  motor  nuclei  of  the  cranial  nerves  are  much  more  frequently  affected 
than  the  sensory  nuclei.  I  have  seen  cases  where  all  the  motor  nuclei 
were  affected  without  derangement  of  sensation.  The  cerebellum  may 
also  be  involved. 

Symptomatology. — The  onset  is  sudden  in  association  with  one  of  the 
above-mentioned  etiological  factors.  There  may  be  in  some  cases  a 
day  or  two  of  prodromal  symptoms:  depression,  irritability,  restlessness, 
etc.  The  period  of  active  symptoms  is  ushered  in  by  a  chill  or  convul- 
sion. If  the  area  of  inflammation  is  extensive  this  is  rapidly  followed 
by  stupor  and  coma.  In  localized  areas  in  the  cortex  both  of  these 
symptoms  may  be  absent.  The  temperature  is  elevated  and  may  rise  as 
high  as  104°  F.,  but  usually  subsides  after  several  days,  falling  slowly  to 
normal.  The  pulse  is  rapid  and  may  be  extremely  so.  The  respirations 
are  usually  regular,  but  may  be  hurried  and  in  severe  cases  may  approach 
the  Cheyne-Stokes  type.  After  the  first  or  second  day  focal  symptoms  • 
depending  on  the  part  of  the  brain  involved  develop.  If  the  cortex  is 
involved,  a  monoplegia  affecting  the  arm  or  leg,  a  hemiplegia,  or  a 
paralysis  localized  to  the  lower  portion  of  the  face  may  be  presented. 
In  other  cases  there  may  be  a  cerebellar  gait  with  nystagmus,  etc. 
When  the  gray  matter  around  the  aqueduct  of  Sylvius  is  aftected  there 
is  a  partial  or  complete  paralysis  of  the  eye  muscles.  When  the  seat 
of  inflammation  is  in  the  pons  or  medulla  any  one  of  the  nuclei  of  the 
cranial  nerves,  several  of  them  or  practically  all  of  them,  may  be  involved, 
with  paralysis  of  function  in  their  distribution.  In  the  severe  cases  the 
patient  may  never  regain  consciousness,  dying  in  the  period  of  coma. 
In  other  cases  a  period  of  excitability  or  even  mania  may  follow  for 
several  days  or  weeks.  In  still  other  cases,  and  this  is  especially  true 
in  voung  children,  imbecility  as  a  resuU  of  deaf-mutism  and  destruction 
of  the  posterior  portion  of  the  brain  on  the  left  side  follows.  Where 
the  disease  process  is  limited  there  is,  as  a  rule,  very  extensive  improve- 
ment following  the  subsidence  of  the  fever  and  the  acute  symptoms. 
It  is  rare  to  have  complete  recovery  of  function.  A  permanent  paralysis, 
more  or  less  extensive,  remains. 

Diagnosis.— This  is  always  diflacult  on  account  of  the  resemblance  to 
meningitis.  The  sudden  onset  with  localization  of  the  functional  dis- 
turban'ce  to  one  definite  part  of  the  brain  to  the  exclusion  of  the  rest  of 
the  brain  mass,  the  absence  of  headache,  retraction  of  the  head  and 
Kernig's  sign,  the  rapid  disappearance  of  the  general  symptoms,  and 
the  pe'rsistent  leukocytosis  should  differentiate  encephalitis  from  menin- 
gitis. 

Treatment.— The  treatment  of  encephalitis  durmg  the  acute  attack 
is  absolute  rest  in  a  quiet  room,  a  liquid  diet,  free  purgation,  and  counter- 
irritation  to  the  nape  of  the  neck  or  over  the  scalp.  This  may  best  be 
obtained  by  blisters  or  the  application  of  leeches.  The  treatment  of 
the  paralysis  does  not  differ  from  that  described  under  Poliomyelitis. 


938  DISEASES  OF  THE  NERVOUS  SYSTEM 


CEREBRAL  SINUS  THROMBOSIS. 

Thrombosis  affecting  the  sinuses  of  the  dura  mater  of  the  brain  may 
be  local  and  confined  to  one  sinus  or  may  be  extensive  and  affect  several. 
A  local  throml)Osis  in  the  lateral  sinus  secondary  to  suppurative  condi- 
tions of  the  middle  e:ir  and  of  the  mastoid  is  most  common.  AVhen 
it  is  extensive  and  widespread  through  many  of  the  venous  channels  of 
the  brain  it  is  secondary  to  some  general  process.  We  may  there- 
fore divide  the  causes  of  sinus  thrombosis  into  local  and  general 
svstemic  causes.  Among  the  local  causes  the  suppurative  conditions  of 
the  middle  ear  and  of  the  mastoid  are  the  most  common  in  childhood 
and  in  adult  life,  less  often  the  cause  in  infancy.  In  infancy  middle- 
ear  disease  most  frequently  gives  rise  to  meningitis.  Among  the  other 
local  causes  a  phlebitis  of  the  ophthalmic  vein  is  most  often  secondary 
to  phlegmons  of  the  orbit,  of  the  eye  itself,  or  of  the  cavities  of  the 
face. 

The  thrombus  formed  in  this  vein  may  extend  to  the  cavernous  sinus 
and  later  to  the  other  sinuses.  Suppurative  lesions  of  the  nasopharynx 
and  of  the  deep  lymph  nodes  of  the  neck  may  also  produce  intracranial 
phlebitis.  The  suppurative  lesions  of  the  scalp  due  to  traumatism, 
erysipelas,  or  anthrax  may  produce  a  venous  infection  carried  by  the 
emissary  veins.  Ostitis  of  the  bones  of  the  skull  due  to  traumatism, 
tuberculosis,  or  syphilis  is  not  an  infrequent  local  factor.  Among  the 
general  systemic  causes  septicemic  and  pyemic  conditions  running 
a  subacute  or  chronic  course  and  associated  with  a  state  of  low 
vitality  are  most  frecjuently  to  be  ftnind.  The  systemic  causes  are  those 
usually  found  in  widespread  sinus  thrombosis  of  infancy.  Among  the.se 
diseases  may  lie  mentioned  the  severe  forms  of  gastroenteritis,  cholera 
infantum,  bronchopneumonia,  tuberculosis,  inherited  .syphilis,  and 
following  acute  conditions  such  as  .scarlet  fever,  typhoid,  and  influenza. 
Middle-ear  disease  may  produce  very  extensive  sinus  thrombosis  through 
a  general  septicemia  independent  of  the  local  irritative  septic  process. 
Bacteriological  investigation  has  shown  the  presence  of  streptococci, 
streptobacilli,  and  the  bacilli  coli  communi.  Tt  would  .seem  that  some 
infection  was  necessary',  because  the  experimental  occlusion  of  a  cere- 
bral sinus  or  even  several  of  them  is  not  followed  by  thrombosis  (Fer- 
rari). 

Pathology. — The  examination  of  the  brain  in  children  dying  from 
thromljosis  reveals  a  hard  clot  in  the  sinus  and  often  an  area  of  red, 
hemorrhagic,  infiltrating  extravasation  in  the  area  of  the  cerebral  veins 
emptying  into  the  affected  sinus.  Extensive  or  capillar}'  hemorrhage 
may  be  present  in  the  meningeal  cavities  and  a  clear  or  bloodv  fluid 
or  gelatinous  exudate  may  fill  the  ventricles.  Section  of  the  brain  in 
the  dark,  hemorrhagic  areas  shows  a  capillar}-  venous  thrombosis  with 
leaking  out  of  the  blood  into  the  cerebral  tissues.  Gross  hemorrhages 
are  rare.  In  the  infectious  processes  a  cerebral  ab.scess  may  follow  if 
life  is  sufficiently  prolonged. 


DISEASES   OF  THE  BRAIN  939 

Symptomatology. — The  onset  is  usually  sudden  with  evidence  of  cere- 
bral or  meningeal  irritation.  Coma  rapidly  supervenes;  vomiting,  con- 
vulsions, headache,  and  rigidity  of  the  muscles  of  the  neck  may  be  present. 
In  the  local  septic  processes  there  is  fever,  whereas  in  the  general 
cachectic  conditions  the  temperature  may  be  subnormal.  The  localizing 
evidences  of  the  thrombotic  process  varies  to  a  certain  extent  with  the 
seat  of  the  thrombosis.  When  the  lateral  sinus  is  affected  the  veins  on 
the  affected  side  of  the  face  and  neck  may  not  be  present  on  inspection, 
whereas  on  the  sound  side  they  have  a  normal  distended  appearance. 
A  local  edema  may  be  found  in  the  mastoid  area  and  may  extend  to  the 
neck  region.  A  hard,  fibrous  cord  may  be  felt  in  the  place  of  the  jugular 
vein,  due  to  the  extension  of  the  thrombus  to  the  veins  of  the  neck. 
The  neck  is  sensitive  to  pressure,  the  muscles  are  rigid,  and  there  may 
be  some  enlargement  of  the  cervical  lymph  nodes.  Paralysis  of  the 
facial  nerve  and  deafness  may  be  present,  due  to  the  local  process  in  the 
ear. 

Thrombosis  of  the  superior  longitudinal  sinus  secondary  to  local 
processes  in  the  nasal  cavities,  the  frontal  or  ethmoidal  sinuses,  or  to  a 
general  septicemic  process,  is  associated  with  cyanosis  of  the  face,  dilata- 
tion of  the  veins  of  the  forehead  and  face,  and  depression  of  the  fontanel. 
The  fontanel  may  become  prominent  from  an  associated  hydrocephalus. 
Diffuse  perspiration  of  the  head  and  neck  and  epistaxis  result  from 
passive  congestion  in  the  areas  drained  by  the  superior  longitudinal 
sinus. 

Thrombosis  of  the  cavernous  sinus  is  associated  with  a  slight  exoph- 
thalmos of  the  affected  side,  amblyopia,  paralysis  of  muscles  of  the  eye, 
marked  congestion  of  the  veins  of  the  retina,  edema  and  swelling  of  the 
optic  disk,  and  a  cyanotic  or  red  edema  of  the  upper  eyelid  and  of  the 
forehead.  As  the  thrombotic  process  progresses  the  other  eye  may 
become  affected,  and  these  symptoms  may  be  associated  with  those 
above  described,  due  to  the  extension  of  the  process  into  the  other  sinuses. 
When  hydrocephalus  develops  there  is  coma,  with  vomiting,  protrusion 
of  the  fontanel,  the  hydrocephalic  cry,  and  convulsions.  A  purulent 
process  may  develop  at  any  time  either  in  the  brgiin  or  in  the  local  sinuses, 
and  its  occurrence  depends  on  the  vitality  of  the  child  and  the  patho- 
genic intensity  of  the  infecting  agent. 

Diagnosis. — The  diagnosis  from  meningitis  is  in  most  cases  impossible. 
This  is  especially  true  in  suppurative  conditions  of  the  middle  ear  and 
of  the  mastoid.  The  presence  of  the  edema  about  the  mastoid  and  the 
neck,  and  a  clot  extending  into  the  jugular  vein,  will  often  lead  to  the 
correct  diagnosis.  In  extensive  sinus  thrombosis  the  marked  cyanosis 
of  the  face,  the  epistaxis,  the  examination  of  the  eye-grounds,  the  low 
condition  of  the  vitality  of  the  patient,  and  the  weakened  heart  action 
should  lead  to  a  presumptive  diagnosis.  Abscess  of  the  brain  is  not 
infrequently  a  direct  result  of  the  thrombotic  process,  but  the  differ- 
ential diagnosis  is  of  no  great  importance,  because  in  both  cases  an 
operation  is  demanded  which  will  in  itself  reveal  tlie  exact  stage  of  the 
process.     Abscess  of    the  brain  from  middle-ear  disease  may   affect 


940  DISEASES  OF  THE  NERVOUS  SYSTEM 

either  the  teniporosphenoidal  lobe  or  the  cerebellum.  In  the  former 
case  there  would  be  word  deafness — i.  e.,  inability  of  the  child  to  react 
to  spoken  conimauds,  but  reaction  to  gestures,  such  as  sticking  out  of 
the  tongue  after  the  examiner,  etc.  In  abscess  of  the  cerebellum  there 
may  be  nystagmus,  clumsiness  of  the  same  side  of  the  body,  and  a 
forced  position,  the  child  always  lying  on  the  same  side  and  return- 
ing to  it  if  disturbed.  The  presence  of  high,  irregular  fev(T,  with  irreg- 
ular chills  and  sweats,  and  a  high  leukocytosis  with  or  without  the 
above  symptoms  should  lead  to  a  diagnosis  of  abscess.  Abscess  may 
be  present,  however,  with  a  normal  or  subnormal  temperature.  (Jlde 
infra.) 

Pro^osis. — Thrombosis  of  the  cerebral  sinuses  is  a  rapidly  fatal 
affection  in  early  childhood;  death  usually  supervenes  in  a  few  days. 
In  rare  cases,  and  especially  in  later  childhood,  the  duration  may  be 
longer  and  may  even  extend  into  weeks.  If  the  irritative  process  be 
promptly  removed  a  local  thrombosis  may  in  rare  cases  go  on  to  resolu- 
tion, with  channelling  of  tlie  thrombosis  or  complete  obliteration  of  the 
sinus  and  recovery.  In  such  cases,  however,  a  sclerosis  of  the  brain  or 
hydrocephalus  remains. 

Treatment. — In  extensive  thrombosis  of  septicemic  origin  the  treat- 
ment can  only  he  palliative,  such  as  is  that  employed  in  meningitis.  An 
attempt  should  be  made  in  all  cases  to  control  as  far  as  possible  the 
source  of  infection,  and  to  increase  the  nutrition  of  the  child  by  over- 
feeding and  stimulation.  The  treatment  of  local  thrombosis  is  surgical. 
A  complete  removal  and  cleansing  of  the  local  septic  process,  with 
removal  of  the  clot  from  the  sinus,  and  control  of  the  hemorrhage  by 
tampons  of  iodoform  gauze  is  indicated.  Care  should  be  taken  to 
exclude  the  possibility  of  an  abscess  of  the  brain  before  the  wound  is 
closed.  Surgical  treatment  is  now  much  better  understood  than  formerly 
and  an  operation  may  save  the  life  of  a  child. 


ABSCESS  OF  THE  BRAIN. 

Abscess  of  the  Brain,  a  comparatively  rare  condition  in  the  adult,  is 
of  much  more  frecpient  occurrence  in  childhood  on  account  of  the  fre- 
quency of  purulent  conditions  of  the  mifldle  ear  and  of  the  mastoid. 

Etiology. — It  may  l)e  stated  as  a  general  rule  that  a  pyogenic  infection 
is  necessary  for  the  production  of  an  abscess  within  the  cranial  cavitv. 
The  so-called  idiopathic  or  primary"  brain  abscess  is  merelv  a  confes- 
.sion  of  ignorance  as  to  the  source  of  infection.  A  localized  abscess  fol- 
lowing traumatism  or  infection  may  be  walled  off  and  remain  latent  for 
years,  to  reappear  with  marked  symptoms  after  a  slight  or  extensive 
injury  to  the  skull;  this  is  the  explanation  of  many  of  the  so-called 
idiopathic  abscesses.  I  have  seen  two  abscesses  the  size  of  hazel- 
nuts, one  in  either  hemisphere  of  the  brain,  walled  off  from  the 
rest  of  the  brain  by  an  old  inflammatory  capsule,  and  producing  neither 
general   nor   localizing  symptoms,  and  discovered   by  accident   at  the 


DISEASES  OF  THE  BRAIN  941 

autopsy.  This  condition  is,  however,  of  much  less  frequent  occurrence 
in  childhood  than  in  later  life,  and  even  here  it  occurs  infrequently. 
Septic  infection  from  structures  in  direct  relation  to  the  intracranial 
cavity  is  by  far  the  most  usual  cause  of  brain  abscess  in  childhood. 
Purulent  processes  in  the  mastoid  area  and  middle  ear  in  later  childhood 
may  give  rise  to  abscess  of  the  brain,  extradural  abscess,  thrombosis  of 
the  sinus,  or  acute  meningitis.  In  many  cases  one  or  more  of  these 
may  be  combined.  When  the  extension  of  the  process  is  direct  the  dura 
first  becomes  involved,  followed  by  a  localized  or  general  involvement 
of  the  pia  and  arachnoid,  and  later  of  abscess  within  the  brain.  The 
extension  may  occur  through  lymphatic  channels,  and  an  abscess  of  the 
brain  substance  may  be  present  without  involvement  of  the  meninges. 
When  the  infection  extends  from  the  roof  of  the  mastoid  cavity  the 
abscess  is  usually  found  above  the  tentorium,  and  localized  either  in  the 
temporosphenoidal  lobe  or  posterior  to  this  in  the  occipital  area.  When 
the  infection  extends  from  the  posterior  wall  the  cerebellum  is  usually 
involved,  with  or  without  thrombosis  of  the  lateral  sinus.  When  the 
infection  is  due  to  extension  from  the  nasal  cavities,  the  frontal  or 
ethmoidal  sinuses,  the  abscess  is  usually  found  in  the  frontal  lobe,  with 
or  without  meningitis  of  the  anterior  fossa?  of  the  skull. 

Next  in  frequency  to  the  above  causes  traumatism  is  the  most  impor- 
tant factor  in  childhood.  The  traumatic  infection  may  occur  with  or 
without  lesions  of  the  superficial  tissues.  Localized  abscesses  of  the 
scalp,  fracture  or  necrosis  of  the  cranial  bones,  and  punctured  wounds 
are  among  the  causes  found.  Purulent  meningitis,  a  local  abscess 
beneath  the  dura,  or  an  abscess  within  the  brain  without  meningeal 
involvement  may  be  so  produced. 

Cerebral  abscesses  as  a  result  of  a  general  pyemic  condition  may  be 
found  scattered  throughout  the  brain,  but  are  of  such  infrequent  occur- 
rence in  childhood  as  to  demand  little  consideration.  A  septic  infection 
of  an  extensive  sinus  tlirombosis  may  result  in  extensive  and  multiple 
abscess  formation. 

Pathology. — In  the  great  majority  of  cases  the  abscess  is  solitary 
and  infiltrating.  It  is  much  more  extensive,  as  a  rule,  when  the 
cerebrum  is  affected  than  when  it  is  situated  below  the  tentorium.  The 
abscess  cavity  varies  greatly  in  size,  in  some  cases  being  so  small  as  to 
escape  careful  exploration  in  its  immediate  neighborhood  during  an 
operation.  Smaller  abscesses  are,  as  a  rule,  fairly  well  separated 
from  the  unaffected  brain  substance  by  an  inflammatory  wall, 
and  the  blunt  edge  of  a  grooved  director  may  easily  pass  over  it 
without  penetrating  the  abscess  cavity.  In  other  cases  the  abscess  may 
destroy  a  large  part  of  the  cerebral  hemisphere;  there  is  no  distinct 
wall;  the  brain  substance  in  the  immediate  neighborhood  is  very  edema- 
tous, and  microscopic  section  shows  marked  round-cell  infiltration 
extending  into  normal  tissue.  Encapsulation  of  an  abscess  may  be 
fairly  well  developed,  and  yet  a  secondary  extensive  abscess  may  form 
in  its  immediate  neighborkood.  The  examination  of  the  contents  of 
the  abscess  cavity  shows  a  greenish-yellow  or  reddish-brown  fetid  pus, 


94  2  DISEASES  OF  THE  NER  VO  US  S YSTEM 

containing  Irukotytcs,  pus  cells,  destroyed  brain  tissue,  and  infecting 
niicr()-or<;anisnis.  Streptococci,  sta])hyl()cocci,  pneumococci,  and  the 
l)a(illus  pyocyancus  have  been  found  in  the  pus. 

Symptomatology. — The  .symptoms  of  brain  abscess  in  children  vary 
grcatlv  widi  the  intensity  of  the  process  and  the  presence  or  absence 
of  coniplicatint;  lesions  of  the  meninges  or  of  the  cerebral  sinuses.  The 
svniptouis  may  develop  rapidly  after  operations  on  the  middle  ear  or  on 
the  mastoid,  l)ut  otherwise  are,  as  a  rule,  of  slow  onset,  but  running  a 
ra])id  course  after  the  complete  formation  of  the  suppurating  process. 
In  a  child  who  has  chronic  ear  disease,  persistent  headache,  irritability, 
and  mental  dulness  may  be  the  first  evidence  of  intracranial  involve- 
ment. The  headache  comes  in  paroxysms,  and  may  occasionally  be 
associated  with  vomiting.  After  several  days  or  a  week,  or  in  some  ca«es 
several  weeks,  the  symptoms  are  markedly  accentuated,  the  headaches 
become  constant,  the  patient  becomes  anemic  and  sallow,  there  is  a 
slight  rise  of  temperature  with  marked  loss  of  mental  power,  mental 
and  jihvsical  fatigue,  coating  of  the  tongue,  nausea,  and  vomiting. 
When  this  stage  is  reached  the  disease  runs  a  rapid  course.  The  tem- 
perature now  drops  to  normal  or  subnormal,  unconsciousness  develops, 
the  pupils  become  unequal,  optic  neuritis  may  be  present,  and  there  is 
often  paralysis  of  the  opposite  side  of  the  body.  The  pulse  may  remain 
normal,  but  is  usually  slowed;  the  respirations  become  slow  and  may  be 
of  a  Cheyne-Stokes  type. 

In  some  cases  (a  comparatively  small  munber)  there  is  evidence  of  a 
general  septic  infection.  The  temperature  remains  high  throughout 
the  disease  or  may  be  very  irregular  with  irregular  chills  and  sweats, 
but  even  in  these  cases  the  pulse  remains  slow  until  late  in  the  disease. 
In  other  cases  the  temperature  remains  normal  or  sui)normal  until  the 
last  day  or  two,  when  it  may  ascend  to  103°  or  104°  F.  Sudden  death 
sometimes  occurs  from  a  rupture  of  the  ai)scess  cavity  into  the  surround- 
ing brain  substance.  Localization  of  the  abscess  is  difficult  on  account 
of  its  infiltrating  character.  When  the  temporosphenoidal  lobe  of  the 
brain  is  affected  it  may  be  localized  in  some  cases  by  a  careful  examina- 
tion for  aphasia.  This,  however,  implies  a  fairly  good  m.ental  reaction 
of  the  patient,  which  is,  however,  very  apt  not  to  be  present  in  abscess 
complicating  middle-ear  disease.  An  abscess  in  the  temporosphenoidal 
area  usually  destroys  the  connection  between  the  auflitory  and  visual 
speech  area;  as  a  result  of  this  when  the  patient  is  shown  an  object 
of  common  u.se,  he  is  not  able  to  recall  the  name  of  it,  although 
he  may  be  able  jx'rfectly  to  appreciate  its  purposes  and  uses  or  even 
in  some  cases  to  descrilie  it.  If  the  al)scess  is  sufficiently  extensive 
to  destroy  the  visual  areas  in  the  occipital  lobe,  or  the  optic  radia- 
tions transmitting  impulses  to  them,  hemianopsia  may  be  present.  The 
extension  of  the  abscess  in  an  anterior  direction  may  involve  the  motor 
fibres  and  produce  paralysis  of  the  opposite  side  of  the  Ixxly. 

An  abscess  below  the  tentorium  in  the  cerebellum  gives  rise  to  per- 
sistent vomiting,  optic  neuritis,  marked  vertigo,  nystagmus,  and  a  very 
ataxic  gait  like  that  of  a  drunken  man.    The  knee-jerk  on  the  same  side 


DISEASES  OF  TEE  BRAIN  943 

or  on  both  sides  may  be  absent,  and  there  may  be  a  marked  dumsiness 
and  slowness  of  movement  of  the  extremities  on  the  same  side  as  the 
lesion.  Facial  paralysis  may  be  present,  due  to  the  'pressure  on  the 
facial  nerve  or  from  involvement  of  the  pons.  This  may  also  be  due 
to  the  local  process  in  the  middle  ear. 

Diagnosis. — Where  a  source  of  infection  can  be  determined,  such  as 
that  following  traumatism  or  evidence  of  a  local  inflammatory  disease 
of  the  brain  tissues  in  direct  connection  with  the  seat  of  infection,  it 
makes  the  diagnosis  comparatively  easv. 

Abscess  of  the  brain  complicating  middle-ear  disease  must  be  differ- 
entiated from  sinus  thrombosis  and  meningitis.  The  percentage  of 
cases  of  abscess,  of  thrombosis,  and  of  meningitis  complicating  ear  dis- 
ease varies  in  each  of  these  from  30  to  35  per  cent.  Thus  in  Poulsen's 
36  cases  of  complications  of  ear  disease  there  were  13  cases  of  abscess, 
12  of  thrombosis,  and  11  of  meningitis. 

Sinus  thrombosis  gives  a  higher  temperature,  as  a  rule,  with  a  rapid 
pulse,  with  tenderness  in  the  region  of  the  mastoid  or  of  the  neck,  throm- 
bosis of  the  deep  veins  of  the  neck,  cyanosis,  and  sweating.  All  the 
considerations  given  above  under  Sinus  Thrombosis  (p.  938)  must  be 
taken  into  account. 

In  meningitis  the  onset  is  usually  much  more  rapid  and  the  course  of 
the  disease  much  shorter  than  in  brain  abscess.  The  temperature  here 
again  is  higher,  often  fluctuating,  associated  in  the  early  stages  with 
slowing  of  the  pulse,  and  later  with  a  rapid,  irregular  pulse,  hyperesthesia 
to  light  and  sound,  persistent  headache,  twitching  of  the  extremities, 
rigidity  of  the  neck,  retraction  of  the  head,  and  a  purulent  fluid  on 
spinal  puncture,  or  evidence  of  the  infecting  agent  in  the  cerebrospinal 
fluid — i.  e.,  when  the  connection  between  the  area  of  meningitis  and 
the  spinal  meninges  remains  open. 

In  traumatic  cases  brain  abscess  must  at  times  be  differentiated 
from  brain  tumor.  A  beginning  or  latent  brain  tumor  in  a  child  may 
show  evidence  of  very  rapid  growth  after  traumatism  to  the  head.  In  a 
case  of  a  boy  of  four  years  recently  reported  by  me,  with  Dr.  J.  H. 
Jopson,  the  following  symptoms  were  presented ; 

The  symptoms  were  of  seven  weeks'  duration,  and  began  with  drowsi- 
ness quickly  followed  by  left-sided  hemiplegia,  headache,  restlessness, 
and  night -cries;  vomiting  and  partial  incontinence  of  urine  were  also 
present.  There  was  a  partial  return  of  power  in  the  left  leg  after  two 
weeks,  and  consciousness  and  speech  were  preserved  until  shortly  be- 
fore death.  Fever  and  convulsions  were  absent.  The  pulse  was  55  on 
the  day  of  admission  to  the  hospital.  A  few^  hours  later  he  became 
unconscious;  the  pulse  became  rapid  and  weak,  the  temperature  rose, 
and  the  symptoms  of  fatal  paral}iic  compression  of  the  brain  were 
present. 

The  patient  was  trephined  the  same  night,  in  the  hope  that  a 
hemorrhage  or  a  collection  of  pus  might  be  evacuated,  as  there  was  a 
history  of  a  fall  preceding  his  illness,  but  nothing  was  discovered,  and 
he  died  shortly  afterward. 


944  DISEASES  OF  THE  NERVOUS  SYSTEM 

On  autopsy,  a  gelatinous  tumor,  with  areas  of  hemorrhagic  extrava- 
sation, was  found  to  occupy  the  anterior  two-thirds  of  the  right  hemi- 
sphere. It  began  immediately  beneath  the  ependyma  of  the  third  ven- 
tricle, and  extended  to  the  external  capsule.  The  anterior  third  of  the 
internal  capsule  was  infiltrated  by  the  tumor-nuiss.  At  no  point  tlid 
the  tumor  reach  within  an  inch  of  the  cortical  surface.  Microscopic 
examination  showed  a  neuroglioma,  composed  entirely  of  neurogliar 
nuclei  and  fibres.  The  tumor  was  of  central  origin,  of  an  infiltrating 
character,  and  inoperable. 

A  careful  histoiy  of  the  case  will  often  show  evidence  of  cerebral 
irritation  before  the  traumatism.  The  intracranial  pressure  of  a  tumor 
is  more  marked;  the  optic  neuritis  develops  early,  is  much  more  intense 
and  is  present  in  a  much  larger  number  of  cases  (80  to  !)(J  per  cent.). 
There  is  no  fever  and  symptoms  of  local  brain  irritation  are  more  posi- 
tive and  prolonged  than  in  abscess. 

Prognosis. — \Miere  distinct  abscess  formation  is  present  in  the  brain 
tissue  the  prognosis  depends  upon  the  cause  of  the  abscess,  the  extent 
of  brain  involvement,  and  the  period  of  evacuation.  In  infiltrating 
abscess  complicating  middle-ear  disease  the  prognosis  is  unfavorable, 
because  it  is  rare  in  such  cases  to  find  the  abscesses  encapsulated. 
Oppenheim's  statistics  show  96  out  of  196  cases  cured.  In  traumatic 
abscess  3S  cases  out  of  60  recovered. 

Treatment. — The  treatment  of  brain  abscess  is  entirely  surgical. 
Evacuation  and  drainage  of  the  abscess  cavity  are  absolutely  necessary. 
The  necessity  of  early  operation  should  be  insisted  upon.  This  is  espe- 
cially true  in  cases  of  middle-ear  disease.  The  difficulty  of  making  a 
positive  diagnosis  of  meningitis  or  sinus  thrombosis  shoukl  not  deter 
from  early  operative  procedure.  When  in  the  course  of  middle-ear  or 
mastoid  disease  there  is  distinct  evidence  of  intracranial  involvement, 
and  especially  when  this  evidence  points  to  local  brain  irritation  and  is 
progressive  in  spite  of  local  treatment,  an  operation  should  be  done  to 
relieve  the  local  l)one  condition  and  to  exclude  the  possibility  of  sinus 
thrombosis,  meningitis,  or  abscess.  This  treatment  is  necessary  in  any 
one  of  the  three  conditions  named.  Exploration  of  the  brain  under 
aseptic  procedure  should  be  carefully  and  thoroughly  carried  out.  Inas- 
much as  a  grooved  director  may  easily  slip  over  the  wall  of  an  abscess 
cavity,  an  instrument  with  a  sharp  point  or  even  free  incision  with  the 
knife  should  be  employed.  In  the  temporosphenoidal  lobe  of  the  brain 
and  in  the  cerebellum  this  will  do  no  harm,  other  than  a  possible  hemor- 
rhage due  to  the  cutting  of  a  vessel  which  can  be  easily  controlled.  Ex- 
ploration of  the  cerebellum  should  never  be  neglected  when  an  explora- 
tion of  the  temporal  sphenoidal  lobe  gives  negative  results. 


TUMORS  OF  THE  BRAIN. 

Tumors  of  the  brain  are  of  not  infrequent  occurrence  in  childhood. 
Starr  has  collected  300  cases  under  nineteen  years  of  age,  as  follows; 


DISEASES  OF  THE  BRAIN  945 

Nature  of  Tumor.  Position. 

Tuberculous  tumors 152       Cerebellum 96 

Glioma 37       Pons  varolii 38 

Sarcoma 34       Centrum  ovale 35 

Gliosarcoma 5      'Basal  ganglia  and  lateral  ventricles       .       .  27 

tJystic 30       Cerebral  cortex 21 

Gummata 2       Corpora  quadiigemina  and  crura  cerebri      .  21 

Other  varieties 30       Base 8 

Fourth  ventricle 5 

Medulla 6 

Multiple  tumors 43 

It  necessarily  follows  from  the  above  classification,  and  this  agrees 
with  my  own  experience,  that  tuberculous  tumors  are  those  usually  met 
with  in  children.  Gliomata  and  sarcomata  are  occasionally  met  with, 
the  other  forms  being  very  rare. 

Pathology. — Tuberculous  tumors  may  occur  as  solitary  or  multiple 
growths.  They  are  more  frequently  met  with  as  multiple  tumors  than 
any  of  the  other  varieties  in  the  above  classification.  They  may  affect 
any  part  of  the  central  nervous  system.  They  are  most  frequently  met 
with  at  the  base  of  the  brain  between  the  crura,  in  the  neighborhood 
of  the  fissure  of  Sylvius  and  near  the  median  line  of  the  cortex.  They 
vary  in  size  from  8  mm.  to  4  cm.,  and  show  a  marked  tendency  to  become 
encapsulated.  The  capsule  is  formed,  when  the  tumor  is  situated  deep 
in  the  brain  substance,  by  a  zone  of  proliferated  neuroglia  cells,  and 
when  they  occur  on  the  surface,  by  the  thickened,  infiltrated,  adherent 
pia  mater.  The  encapsulation  is  in  reality  only  a  pseudoencapsulation, 
inasmuch  as  the  thickened  zone  of  glia  cells  is  a  part  of  the  inflammatory 
process  itself,  and  as  a  result  of  this,  attempts  at  removal  usually  result  in 
failure  or  are  only  accomplished  at  the  expense  of  considerable  unin- 
volved  brain  substance.  Section  of  tuberculous  tumors  of  large  size 
may  show  a  very  friable  interior,  but  distinct  softening  or  complete 
breaking  down  is  exceptional.  In  tumors  persisting  for  a  long  time 
partial  or  complete  calcification  may  occur.  In  a  tumor  recently  re- 
moved at  autopsy  in  a  woman  aged  twenty-six  years,  at  the  Henry 
Phipps  Institute,  the  tumor  had  lasted  from  early  childhood.  Active 
symptoms  of  brain  tumor  were  then  present,  but  had  subsided  leaving 
the  girl  completely  blind,  and  with  symptoms  of  cerebellar  irritation; 
complete  calcification  of  the  tumor  had  occurred  with  small  cystic  cavities 
containing  a  clear  fluid  within  the  calcified  mass.  The  involvement  of 
the  brain  tissue  may  be  by  infiUration  and  destruction  of  the  area 
involved,  but  is  more  frequently  a  local  infiltration  with  an  accumulation 
of  new  cells  about  the  central  area,  the  formation  of  the  tumor  respect- 
ing the  nervous  tissue  and  producing  disturbance  of  function  by  pressure 
upon  it.  The  microscopic  examination  gives  the  raked-field,  granular 
appearance  at  the  centre  of  the  tumor,  with  a  zone  of  epithelioid  and 
giant  cells  at  the  periphery.  In  active  tumors  the  tubercle  bacilli  can 
be  demonstrated  in  the  tissues  and  offer  a  differential  diagnosis  between 
tuberculoma,  gummata,  and  degenerating  sarcomata. 

Gliomata  are  infiltrating  tumors  of  rapid  growth  and  develop  imme- 
diately beneath  the  gray  matter  either  of  the  ventricle  or  of  the  cortex 


946  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  involve,  as  a  rule,  large  areas  of  brain  substance.  The  tumor  mass 
is  soft,  almost  pulpy,  very  vascular,  at  times  infiltrated  with  hemorrhagic 
areas  and  surrt)unde(l  by  edematous  brain  tissue.  There  is  no  attempt 
at  encapsulation,  and  it  is  often  only  with  difficulty  that  the  boundary 
of  the  tinnor  mass  can  be  determined  by  the  naked  eye  at  autopsy. 
Sarcomata  resemble  in  their  gross  characteristics  the  gliomata,  but  are, 
as  a  nde,  of  nnich  firmer  consistence  and  not  infrefpiently  encapsulated. 
This  is  especially  true  of  tumors  of  this  class  growing  from  the  bones 
of  the  skull  or  the  membranes  of  the  brain  and  extending  into  the  brain 
substance.  Sarcomata  may  also  grow  from  the  bloodvessels  within  the 
brain  substance.  Sarcomata  nuiy  occur  as  nuiltiple  tumors,  but  not 
with  the  same  fre(iuency  as  the  tuberculous  type  of  tumors.  Very 
vascular  sarcomata  sometimes  develop  within  the  ventricles  of  the 
brain  from  the  choroid  plexus. 

Cystic  tumors  of  the  brain  do  not  differ  in  their  characteristics  from 
these  growths  met  elsewhere  in  the  body.  Among  these  tumors  have 
been  described  parasitic  cysts  such  as  the  echinococcus  and  cysticercus 
celhdosa>,  dermoid  cysts,  etc. 

Symptomatology. — We  may  divide  the  clinical  manifestations  of 
tumors  within  the  cranial  cavity  into  those  caused  by  an  increase  of  the 
intracranial  pressure  and  the  associated  hydrocephalus  which  is  not 
infrequently  associated  in  children  and  those  due  to  a  local  disturbance 
of  function  of  the  particular  part  of  the  brain  involved. 

General  Si/mpioms. — We  must  depend  for  our  diagnosis  of  the  pres- 
ence of  a  brain  tumor  upon  certain  general  symptoms.  Not  infre- 
cjuently,  and  this  is  especially  true  in  children,  the  general  symptoms 
of  marked  intracranial  pressure  may  be  the  only  symptoms  presented. 
This  will  be  the  case  when  the  so-called  silent  areas  of  the  brain  are 
involved  or  where  important  functional  areas  are  involved  only  by 
pressure  and  this  pressure  is  of  very  gradual  evolution. 

The  symptoms  presented  are  of  insidious  onset  and  of  slow 
development.  Exacerbations  may  occur  and  a  slowly  developing  tumor 
may  be  transformed  into  a  rapidly  growing  one  by  traimiatism,  or, 
more  rarely,  by  the  development  of  some  intercurrent  infection. 

Headache  is  an  early  symptom  and  persists  throughout  the  course 
of  the  disease.  It  is  usually  diffuse,  although  it  may  be  localized  to 
the  occiput  in  tumors  of  the  posterior  fossae  of  the  skull.  It  varies  in 
intensity;  at  times  of  a  dull,  gnawing  character;  at  others,  of  an  acute 
agonizing  kind,  described  by  the  patient  as  if  the  brain  were  being 
pulled  out  by  sharp  hooks.  Headaches  may  be  paroxysmal  in  type 
and  associated  with  vomiting.  In  tumors  involving  the  meninges  or 
causing  distinct  local  pressure  on  the  meninges  the  pain  may  be  distinctly 
localized  and  associated  with  marked  tenderness.  This,  however, 
should  never  be  depended  upon  for  localization  unless  the  other  focal 
symptoms  about  to  be  descril)ed  correspond.  The  headache  increases 
in  intensity  up  to  the  point  of  maximal  intracranial  pressure  and  is 
usually  less  severe  in  the  later  stages  of  the  disease.  Headache  may  be 
associated  very  early  in  the  disease  with — 


DISEASES   OF  THE  BRAIN  947 

Convulsions.— These  do  not  differ  from  convulsive  seizures  due  to 
other  causes  in  children.  They  vary  in  frequency  and  in  intensity. 
As  a  rule,  they  occur  at  long  intervals,  but  several  may  be  present  in 
a  single  day.  Convulsive  seizures  may  last  only  a  few  seconds  or  may 
be  prolonged  for  several  minutes.  They  may  be  so  slight  as  to  cause 
only  a  momentary  loss  of  consciousness  with  sKght  rigidity,  or  they  may 
be  so  intense  as  to  produce  marked  exhaustion.  The  general  convulsions 
should  be  differentiated  from  the  local  Jacksonian  convulsion  limited 
to  one  part  of  the  body  and  due  to  local  irritation  of  the  motor  cortex. 
(Vide  infra.) 

Optic  Neuritis. — The  examination  of  the  eyes  early  in  the  disease  will 
show  either  a  distinct  optic  neuritis  or  a  marked  congestion  and  swelling  of 
the  disk,  wliich  later  develops  into  optic  neuritis  as  the  pressure  increases. 
Tliis  is  present  in  89  per  cent,  of  cerebellar  tumors,  the  most  common 
seat  of  tumor  formation  in  childhood.  It  is  present  in  80  per  cent,  of 
all  cases;  it  may  be  associated  with  gradual  impairment  of  the  \dsion, 
going  on  to  complete  bhndness.  Not  infrequently  in  children  sudden 
blindness  occurs.  Tliis  is,  however,  probably  due  to  the  fact  that 
previous  defect  of  vision  was  not  noticed.  All  suspicious  cases  should 
be  carefully  examined  by  the  ophthalmoscope  even  where  defect  of 
vision  is  not  complained  of. 

In  a  brain  tumor  in  a  boy  of  eight  years,  recently  under  my  obser- 
vation, a  marked  choked  disk  was  present  in  spite  of  the  fact  that  the 
boy  spent  several  hours  a  day  reading. 

Vomiting. — Vomiting  is  of  frequent  occurrence  and  is  seen  much 
more  often  in  children  than  in  adults.  It  occurs  independently  of  the 
ingestion  of  food  and  later  may  be  unassociated  with  nausea.  The 
vomiting  in  some  cases  is  more  or  less  continuous  and  leads  to  a  very 
rapid  loss  of  strength.  It  is  sometimes  brought  on  by  simple  change 
of  position  or  even  movement  of  the  head.  In  other  cases  it  is  dependent 
upon  the  presence  of  vertigo.  This  is  often  an  early  symptom  and  may 
be  slight  or  very  intense.  It  usually  occurs  in  paroxysms  at  intervals  of 
longer  or  shorter  duration.  During  the  attack  there  may  be  only  a 
slight  dizziness  where  everything  about  appears  to  be  moving  or  the 
patient  may  have  a  sensation  of  turning  or  sinking  and  may  suddenly 
fall  to  the  floor  during  the  attack. 

As  the  disease  advances  distinct  mental  disturbance  becomes  mani- 
fest. This  symptom  is  present  in  tumors  affecting  any  part  of  the  brain, 
but  is  more  marked  and  develops  earlier  in  tumors  affecting  the  frontal 
lobe.  It  is  also  more  distinct  where  headaches  are  frequent  and  in- 
tense. There  is  usually  progressive  deterioration  of  all  the  mental  fac- 
ulties. There  is  loss  of  intensity  of  concentration  early  associated  with 
the  failure  of  the  memory.  The  child  ceases  to  care  to  play  and 
manifests  during  the  day  a  peevish  attitude;  affectionate  children  ex- 
hibit not  infrequently  complete  indifference  to  those  dear  to  them.  In 
later  stages  of  the  disease  distinct  torpor  develops,  from  wliich  the  child 
with  difficulty  may  be  aroused  and  very  late  complete  unconsciousness 
may  supervene. 


948  DISEASES  OF  THE  NER  VO  US  SYSTEM 

The  pulse  wliic-h  in  the  early  stages  remains  normal  or  is  distinctly 
slowed  becomes  rapid  late  in  the  disease,  the  respirations  slow  and  super- 
ficial. In  older  children  a  humorous  or  witty  cast  of  reply  may  be  given 
in  response  to  all  questions  asked  when  the  tumor  affects  the  frontal 
lobe.  In  the  early  stages  of  tumors  affecting  the  frontal  lobes  in  young 
infants  before  the  cranial  cavity  is  completely  closed  the  increase  in  in- 
tracranial tension  may  lead  to  hydrocephalus.  The  skull  is  enlarged 
in  all  its  diameters.  There  is  a  protrusion  of  the  fontanels  and  separa- 
tion of  the  bones  of  the  skull. 

Symptoms  of  Localization. — The  focal  symptoms  of  brain  tumor,  like 
the  general  symptoms  above  described,  are  of  gradual  development. 
The  higher  development  of  the  left  side  of  the  brain  of  right-handed 
people  and  the  localization  on  the  lefi  side  of  the  brain  of  the  cerebral 
speech  mechanism  makes  the  localization  of  left-sided  tumors  easier 
and  more  acciu-ate  than  those  of  right-sided  lesions.  It  is  often  possible 
to  diagnose  tumors  in  the  frontal  lobes.  The  development  of  marked 
defect  of  mentality  early  in  the  disease  and  a  hinnorous  or  pseudo-witty 
disposition  may  lead  to  a  presumptive  diagnosis  of  frontal  tumor. 
Loss  of  memory,  irritability,  lack  of  concentration,  usually  show,  in 
tumors  elsewhere  in  the  brain,  only  when  the  disease  is  well  developed 
or  even  very  far  advanced,  and  their  early  appearance  is  more  fre- 
quently found  in  frontal  tumors.  This  may  be  confirmed  later  in 
growing  tumors  by  involvement  of  the  motor  areas.  When  the  posterior 
third  of  the  third  frontal  convolution  on  the  left  side  is  affected  this  will 
give,  in  right-handed  children,  disturljance  of  speech — motor  aphasia. 
Disturbance  of  speech  develops  gradually;  at  first  only  a  hesitancy  due 
to  the  loss  of  use  of  certain  words  is  observed,  followed  later  by  com- 
plete loss  of  expression.  Inability  to  write  may  be  associated  when 
the  lesion  is  sufficiently  large  to  involve  the  neighboring  areas  toward 
the  convexity.  In  some  cases  the  aphasia  will  only  be  present  when  the 
child  is  in  an  erect  position  and  the  tumor  pressing  by  its  own  weight 
causes  disturbances  of  function  in  Broca's  area.  Tumors  involving 
the  motor  area,  either  by  extension  or  by  primary  involvement  of  the 
cortex,  give  rise  to  Jacksonian  epilepsy.  Thus,  a  tumor  beginning 
high  up  in  the  motor  area  and  producing  irritation  of  the  leg  centre 
gives  rise  at  first  to  a  local  convulsive  movement  usually  clonic  in 
character,  affecting  the  leg  of  the  opposite  side  of  the  body.  This  will 
be  associated  with  loss  of  power,  at  first  slight,  but  increasing  as  the 
tumor  grows.  As  the  irritation  of  the  cortex  increases  the  other  motor 
centres  mav  be  affected  and  the  convulsion,  at  first  besfinnins:  in  the  leir, 
spreads  to  the  arm  and  later  to  the  face  of  the  same  side  and  may  become 
general,  invoh-ing  both  sides  of  the  body.  As  a  rule,  when  the  convulsion 
is  localized  to  one  extremity  consciousness  is  preserved,  although  it  may 
be  lost  in  ver\'  localized  convulsions.  When  the  convulsion  involves  more 
than  one-half  of  the  body  consciousness  is  lost.  When  the  tumor  begins 
in  the  arm  or  face  areas  the  convulsion  is  at  first  localized  to  these  areas 
and  when  it  becomes  general  begins  in  the  area  of  primary  involvement. 
It  is,  therefore,  of  considerable  diagnostic  importance  that  the  con- 


DISEASES  OF  THE  BRAIN  949 

vulsions  of  brain  tumor  should  be  carefully  watched  and  the  mode  of 
onset  carefully  noted.  The  reflexes  are  increased  and  when  the  motor 
area  is  involved  the  Babinski  reflex  (extension  of  the  toes)  is  present, 
with  ankle  clonus. 

Tumors  in  the  superior  parietal  lobe  are  associated  with  astereognosis 
— an  inability  to  recognize  or  name  objects  by  handling  them.  Tumors 
in  the  superior  parietal  area  usually  involve  the  motor  area  and  later 
produce  Jacksonian  epilepsy  with  loss  of  power  of  the  opposite  side  of 
the  body.  Ataxia  and  some  anesthesia  in  the  opposite  arm  and  leg  may 
be  present  in  superior  parietal  lesions. 

Lesions  of  the  inferior  parietal  lobe  of  the  left  side  (supramarginal 
and  angular  gyri)  produce  word  bhndness.  When  the  letters  of  the 
alphabet  are  shown  to  the  child  it  is  unable  to  recognize  them.  Indi- 
vidual letters  may  be  recognized  with  an  inability  to  understand  simple 
words.  The  cliild  is  able  to  understand  what  is  said  to  it  and  to 
express  itself  in  ordinary  language.  If  the  lesion  extends  deep  in  the 
brain  substance  it  will  involve  the  visual  fibres  going  to  the  cortex  of 
the  occipital  lobe  and  produce  loss  of  vision  in  the  same  half  of  the 
visual  field  in  both  eyes  (homonymous  hemianopsia).  Lesions  of  the 
occipital  lobe  likewise  produce  hemianopsia  and  the  patient  is  able  to 
see  only  objects  on  the  opposite  side  to  the  lesion.  If  a  drinking  cup 
or  cherished  object  is  brought  in  front  of  the  child  from  the  blind  side 
of  the  visual  field  no  attempt  is  made  to  grasp  it  until  it  passes  the 
median  line.  If  it  is  brought  from  the  opposite  side  the  child  imme- 
diately grasps  it  as  soon  as  it  is  brought  into  the  visual  field.  Tumors 
affecting  the  temporosphenoidal  lobes  of  the  left  side  produce  word 
deafness— i.  e.,  inability  to  understand  spoken  commands.  English 
sounds  to  the  child  like  some  foreign  tongue.  There  is  also  loss  of 
memory,  or  rather  the  inability  to  recall  the  names  of  people  or  places. 
This  is  due  to  the  fact  that  the  memory  of  spoken  words  is  stored 
up  in  the  first  and  second  temporal  convolutions  of  the  left  side  in 
right-handed  people. 

Tumors  lying  deep  in  the  brain  substance  usually  produce  pressure 
on  the  fibres  of  transmission  and  result  in  monoplegia  or  hemiplegia 
without  locaKzed  convulsions,  anesthesia  on  the  opposite  side  of  the 
body,  or  hemianopsia.  Tumors  at  the  base  of  the  brain  can  be  localized 
by  the  involvement  of  the  cranial  nerves.  Each  case  will  have  to  be 
studied  with  reference  to  the  exit  points  and  the  intracranial  course  of 
the  cranial  nerves.  Tumors  of  the  crus  between  the  pons  and  the 
cerebral  hemisphere  (the  crus)  produce  paralysis  of  the  third  nerve 
on  the  affected  side  by  direct  involvement  of  this  nerve  going  to  the  eye 
of  the  same  side  and  paralysis  of  the  face,  arm,  and  leg  of  the  opposite 
side  which  have  not  yet  crossed  to  the  opposite  side  to  supply  those 
structures.  Tumors  of  the  pons  may  produce  a  paralysis  of  the  ex- 
ternal rectus  with  divergence  of  the  eye  of  the  same  side  due  to 
involvement  of  the  sixth  nerve,  and  paralysis  of  the  muscles  of  mastica- 
tion and  of  sensation  on  the  same  side  due  to  involvement  ot  the 
fifth  nerve,  or  of  paralysis  of  the  muscles  of  the  face  due  to  involve- 


950  DISEASES  OF  THE  NERVOUS  SYSTEM 

ment  of  the  seventh  nerve,  any  or  all  of  which  is  associated  with  par- 
alysis of  the  arm  or  letf  of  the  opposite  side  of  the  body.  The  reflexes, 
such  as  the  knee-jerk,  are  often  lost  in  tumors  of  the  pons  and  of  the 
cerebellum. 

In  tumors  of  the  medulla,  paralysis  of  the  tongue  and  of  the  palate, 
with  some  difhculty  of  deglutition  due  to  involvement  of  the  esophagus 
on  the  affected  side,  may  be  associated  with  paralysis  of  the  arm  and 
leg  of  the  opposite  side,  or  all  four  extremities  may  be  paralyzed. 

Tumors  of  the  Cerebellum. — This  is  the  most  frequent  seat  of  cerebral 
tumoi-s  in  childhood  and  the  symptoms  presented  de])end  upon  the  part 
of  the  cerebellum  affected.  When  the  middle  lobe  of  the  cerebellum 
is  affected  or  when  the  tumor  afl'ecting  the  lateral  lobes  is  sufficiently 
large  to  press  upon  it,  or  the  connection  of  the  cerebellum  with  the 
cerebrum  through  the  superior  peduncle  is  interfered  with,  there  results 
a  distinct  and  marked  disturbance  of  gait.  It  is  first  manifested  by 
staggering  with  a  tendency  to  walk  in  one  particular  direction,  either 
to  the  right  or  to  the  left.  The  patient  usually  staggers  in  the  direction 
opposite  to  the  seat  of  the  tumor;  he  may,  however,  tend  to  go  toward 
the  tumor;  so  that  this  is  of  little  value  in  determining  the  side  of  the 
lesion.  In  wellHleveloped  cases  the  gait  becomes  so  ataxic  that  it 
resembles  that  of  a  drunken  person.  When  the  tumor  is  situated  in 
the  lateral  lobe  of  the  cerebeUum  and  produces  irritation  of  the  cere- 
bellar cortex  nystagmus  is  present.  When  the  tumor  develops  on  the 
inferior  surface  of  the  cerebellum  there  is  an  early  involvement  of  the 
cranial  nerves,  associated  with  paralysis  of  the  face  (seventh  nerve), 
deafness  (eighth  nerve),  unilateral  paralysis  of  the  tongue  (twelfth  nerve). 

Diagnosis. — The  diagnosis  of  the  presence  of  a  tumor  within  the 
cranial  cavity  will  depend  upon  the  course  of  the  disease  and  a  careful 
consideration  of  the  presence  of  the  general  symptoms  of  increased 
intracranial  tension  of  slow  and  gradual  development  with  the  presence 
of  one  or  more  groups  of  localizing  symptoms.  The  conditions  from 
which  brain  tumor  mu.st  be  diagnosed  are  abscess  of  the  brain,  subacute 
or  chronic  hydrocephalus,  tul)erculous  meningitis,  and  chlorosis. 

Brain  abscess  runs  a  much  more  rapid  course,  as  a  rule,  or  after 
running  a  comparatively  rapid  course  for  a  short  time  the  symptoms 
subside  to  reappear  later  from  rupture  of  the  capsule  following  traumatism 
or  spontaneously.  The  presence  of  an  infecting  agent,  as  suppurative 
middle-ear  disease,  or  the  occurrence  of  traumatism  is  an  iiuportant 
factor  in  the  diagnosis.  The  course  of  the  symptoms  in  brain  abscess 
is  relatively  rapid,  that  of  tumor  slow  and  gradual.  Even  where  a  latent 
glioma  is  excited  into  activity  by  traumatism  the  subsecpient  course  of 
the  disease  is  gradual  and  progressive,  with  a  predominance  of  the 
irritative  symptoms,  whereas  in  abscess  the  evidence  of  destruction  of 
tissue  occurs  early.  Optic  neuritis  is  of  much  more  frcfjuent  occurrence 
in  tumor  than  in  abscess.  A  slow  pulse  and  subnormal  temperature 
early  in  the  disease  are  in  favor  of  a  diagnosis  of  abscess.  The 
diagnosis  of  ab.scess  should  not  always  be  made  merely  because  there 
is  a  purulent  condition  of  the  middle  ear  or  of  the  mastfiid.    The  course 


DISEASES  OF  THE  BRAIN  951 

of  the  disease  and  the  other  factors  above  referred  to  should  be  taken 
into  consideration.  Two  cases  have  come  under  my  observation  where 
abscess  was  diagnosed  on  account  of  associated  middle-ear  disease  and 
tumors  were  found  at  autopsy. 

Tuberculous  meningitis  may  be  mistaken  for  brain  tumor.  This  is 
especially  true  in  those  cases  of  tuberculous  meningitis  running  a  long 
course  with  little  fever  and  with  a  gradual  development  of  hydrocephalus. 
The  headache,  however,  is  more  severe  in  meningitis ;  there  is  retraction 
of  the  head,  irritation  to  light  and  sound,  and  tubercle  bacilli  in  the 
cerebrospinal  fluid. 

Tumor  of  the  middle  lobe  of  the  cerebellum  pressing  on  the  aqueduct 
of  Sylvius  may  cause  hydrocephalus,  and  in  a  case  of  this  type  coming 
late  under  observation  acute  hydrocephalus  due  to  inflammation  of 
the  lining  membrane  of  the  ventricle  was  diagnosed.  In  simple  chronic 
hydrocephalus  the  disease  runs  a  very  prolonged  course  and  there 
may  be  no  localizing  symptoms.  The  extremities  may  be  rigid  and 
ataxia  may  be  present  in  the  arms,  but  this  is  always  much  more 
marked  in  tumor  at  the  same  stage.  If  the  cranial  nerves  are  involved 
at  all  in  hydrocephalus  it  is  only  late  in  the  disease  and  is  then  due  to 
tension  rather  than  to  irritation.  A  careful  history  of  the  course  of  the 
disease  or  a  careful  study  of  the  patient  if  under  observation  will  make 
the  diagnosis.  In  the  case  above  referred  to  in  a  tumor  of  the  middle 
lobe  of  the  cerebellum  causing  hydrocephalus,  a  re-examination  of  the 
history  revealed  early  evidence  of  local  disease  in  the  cerebellum,  which 
was  later  followed  by  the  hydrocephalus. 

Chlorosis  may  cause  severe  headaches,  defect  of  mentality,  vomiting, 
vertigo  and,  in  a  few  cases,  optic  neuritis,  but  the  absence  of  localizing 
symptoms  and  the  evidence  of  marked  anemia,  both  in  the  appearance 
of  the  patient  and  on  blood  examination,  should  make  a  presumptive 
diagnosis,  which  is  later  confirmed  by  the  disappearance  of  the  symptoms 
with  the  improvement  of  the  blood  condition  under  proper  therapy. 

The  diagnosis  of  the  character  of  the  tumor  must  be  made  by  taking 
into  consideration  the  evidence  of  primary  disease  elsewhere  in  the 
body  and  the  course  of  the  disease  itself. 

The  presumption  in  tumors  of  the  cerebellum  in  childhood  is  that 
we  are  dealing  with  tuberculosis  on  account  of  its  frequency.  The 
presence  of  tuberculosis  elsewhere  in  the  body  is  of  considerable  value. 
Tuberculous  tumors,  as  a  rule,  progress  more  slowly  than  either  sarcoma 
or  glioma.  Gliomata  are  of  much  more  frequent  occurrence  than 
sarcomata  and  are,  as  a  rule,  if  not  always,  single  growths.  Both 
sarcomata  and  tuberculous  tumors  are  not  infrequently  multiple.  Where 
there  is  evidence  of  syphilis  elsewhere  in  the  body  the  presumption  is 
that  we  are  dealing  with  a  gumma. 

Spontaneous  recovery  from  tuberculous  tumors  is  occasionally  seen. 
In  glioma  and  sarcoma  complete  recovery  never  takes  place,  although 
a  spontaneous  arrest  or  temporary  recovery  under  treatment  has  been 
reported.  Starr  reports  two  cases  of  this  type,  both  sarcomata.  In  one 
of  these  the  symptoms  subsided  for  a  period  of  four  months  and  in  the 


952 


DISEASES  OF  THE  NERVOUS  SYSTEM 


other  for  a  period  of  eight  years.     The  duration  of  the  symptoms  of  brain 
tumor  varies  from  several  montlis  to  several  years. 

Prognosis  and  Treatment. — I'rognosis  is  altogether  unfavorable.  Less 
than  10  per  eent.  are  so  situated  or  are  of  sueh  a  nature  as  to  make  opera- 
tion advisable.  Of  the  other  90  per  cent.,  gummata  alone  yield  with 
any  degree  of  frecjuency  to  internal  treatment.  Not  all,  however,  of 
syphilitic  tumors  yield  to  treatment,  and,  on  the  other  hand,  tumors 
other  than  syphilitic  not  infrequently  show  marked  improvement  under 
antisyphilitic  treatment.  It  therefore  follows  that  in  inoperable  tumors 
a  course  of  mercury,  preferably  by  inunction,  associated  with  increasing 
doses  of  iodide  of  potash,  should  be  tried.  Syphilitic  tumors  whicli 
yield  to  medication  show  rapid  improvement  after  a  few  weeks.  The 
treatment,  however,  should  be  kept  up  some  time  after  the  disappear- 
ance of  the  main  symptoms.  The  improvement  obtained  in  tumors 
other  than  gummata  by  mercury  and  the  iodides  is  usually  temporary. 


Fig.  196 


Sarcoma  of  the  head. 


In  inoperable  cases  headache,  vertigo,  vomiting,  and  convulsions  will 
demand  attention.  For  the  headache  phenacetin  or  acetanilid  may  at 
first  be  tried,  Ijut  it  is  usually  necessary  to  resort  to  the  use  of  opium. 
The  vomiting,  the  vertigo,  and  the  convulsions  may  be  relieved  by  the 
use  of  the  bromides  and  a  careful  regulation  of  the  diet.  Where  the 
headaches  are  very  persistent,  and  there  is  marked  optic  neuritis  with 
progressive  failure  of  vision,  trephining  has  l)een  done  with  good  results 
in  some  cases.  In  a  recent  trephined  case  under  my  observation  the 
headaches  have  entirely  disappeared  up  to  the  present  time,  six  weeks 
after  the  operation,  and  the  swelling  of  the  optic  disk  has  entirely 
subsided  with  full  vision  intact. 

Surgical  Treatment. — It  may  be  stated  as  a  general  rule  that  in  tumors 
of  the  cerebrum  if  distinctly  localized,  progressive  in  character,  and  not 
yielding  to  medical  treatment,  trephining  should  be  recommended  both 


DISEASES  OF  THE  BRAIN  953 

as  an  exploratory  and  therapeutic  measure.  It  can  never  be  positively 
stated  whether  a  tumor  is  or  is  not  removable  before  opening  the  skull. 
In  tumors  situated  beneath  the  cortex,  free  incision  into  the  cortex  should 
be  made  if  the  position  of  the  tumor  cannot  be  determined  by  inspection 
or  palpation  of  the  exposed  brain.  In  gliomata  and  sarcomata  attempts 
at  removal  usually  result  in  failure.  The  surgeon  should  recognize 
the  impossibility  of  complete  removal  of  infikrating  tumors,  and  should 
remain  content  with  the  opening  of  the  skull  cavity  for  relief  of  pressure 
when  such  tumors  are  discovered.  It  should  be  remembered  that  tumors, 
either  beginning  in  the  bones  of  the  skull  or  secondarily  infiltrating 
them,  are  associated  with  profuse  bleeding  both  from  the  scalp  and  from 
the  bones  when  operation  is  attempted.  For  this  reason  it  was  deemed 
inadvisable  to  operate  on  the  patient  shown  in  Fig.  196.  Secondary 
infection  from  the  nose  was  also  feared  if  operation  were  attempted  in 
this  case. 

Tumors  at  the  base  of  the  brain  in  the  neighborhood  of  the  fourth 
ventricle  or  of  the  pons,  the  medulla,  or  of  the  optic  thalamus  cannot 
be  removed  on  account  of  the  operative  diihculties  and  the  functions  of 
the  structures  themselves. 

When  operative  procedures  are  necessary  valuable  time  should  not 
be  lost  in  trying  to  get  results  from  drug  treatment.  The  recuperative 
power  of  the  patient  is  better  in  the  earlier  stages  of  the  disease,  and 
when  the  tumor  is  removable  the  insult  to  the  cerebral  tissues  will  be 
less  intense  and  extensive  in  the  earlier  stages  of  growth. 


INTRACRANIAL  HEMORRHAGE. 

Intracranial  Hemorrhage  in  children  may  affect  any  of  the  intracranial 
structures.  We  have,  therefore,  to  deal  with  subdural  hemorrhages,  sub- 
arachnoidal hemorrhages,  and  hemorrhages  into  the  brain  substance. 
In  addition  to  these  there  are  met  with  in  infancy  hemorrhages  beneath 
the  scalp,  and  epidural  hemorrhages  between  the  bones  of  the  skull  and 
the  dura  mater. 

Etiology. — The  causative  factors  in  the  production  of  intracranial 
hemorrhage  may  be  divided  into  those  preceding  birth,  those  operative 
at  the  time  of  birth,  and  those  subsequent  to  birth.  Traumatism  to  the 
mother  in  the  late  stage  of  pregnancy  has  been  shown  to  produce  hemor- 
rhage into  the  brain  substance  (Gibb).  I  have  in  my  collection  the 
brain  of  a  fetus  of  six  months,  the  result  of  a  miscarriage,  with  an  organ- 
ized, subarachnoidal  hemorrhage  covering  one-half  of  a  hemisphere, 
which  must  have  existed  for  a  considerable  time  before  the  miscarriage. 
This  miscarriage  was  spontaneous  and  occurred  while  the  patient  was 
in  the  hospital.  In  another  case  the  child  was  born  at  term,  and  at 
autopsy  a  grumous,  bloody  fluid  occupied  the  posterior  third  of  the 
subdural  space  above  the  tentorium  on  the  right  side.  The  hemisphere 
was  intact  and  covered  by  the  pia  and  arachnoid,  but  had  developed  only 
to  two-thirds  the  size  of  its  fellow-hemisphere.    From  the  character  of  the 


951  DISEASES  OF  THE  NERVOUS  SYSTE3f 

exudate  and  the  failure  of  the  development  of  tiie  hrain  this  hemorrhage 
must  have  taken  j)laee  eoinparatively  early  in  pregnancy. 

Hemorrhage  into  the  cranial  cavity  at  birth  is  most  frecjuently  due 
to  traumatism,  although  it  may  occur  in  perfectly  normal  births.  The 
application  of  forceps  with  or  without  fracture  of  the  i)ones  of  the  skull 
is  a  fre<|uent  cause.  The  application  of  force  applied  to  the  trunk  or 
to  the  extremities  in  l)reech  presentations  or  after  version  nuiy  produce 
the  same  result.  The  traumatism  may  be  a  spontaneous  traumatism 
due  to  long  and  difficult  labor.  A  displacement  of  the  parietal  bones 
with  compression  of  the  superior  longitudinal  sinus  in  some  cases 
produces  a  passive  congestion,  with  distention  of  the  veins  of  the  convexity 
and  a  ruj)ture  of  these  veins  either  into  the  meningeal  cavity  or  into 
the  brain  substance. 

Compression  of  the  cord  or  interference  with  the  venous  circulation 
returning  from  the  brain  by  malposition  of  the  cord  around  the  neck 
may  be  a  causative  factor.  It  will,  therefore,  lie  seen  that  the  iiemor- 
rhage  at  birth  in  most  cases  is  venous  in  ty])e,  and  when  arterial  hemor- 
rhage occurs  there  is  direct  traumatism  to  the  head  with  fracture  or  a 
free  disposition  to  rupture  from  arterial  disease  due  to  liereditary 
syphilis  or  other  causes. 

Hemorrhage  aft(T  birth  and  during  childhood  is  most  frequently 
associated  with  simis  thrombosis  above  described,  or  as  the  result  of  an 
inflammatory  process  of  the  brain  in  association  with  some  acute 
infection.  Passive  congestion  due  to  tuberculous  disease  of  the  medias- 
tinum or  hypertrophy  of  the  thymus  gland  may  lesid  to  meningeal 
heiuorrhage. 

Cerebral  hemorrhage  in  late  childhood,  apart  from  the  meningeal 
hemorrhage  due  to  traumatism  or  rupture  of  the  luiddle  meningeal  or 
of  its  branches,  is  of  rare  occurrence.  Two  cases  have  come  under  mv 
observation,  one  immediately  following  scarlet  fever,  the  other  after 
diphtheria.  The  proi)al)le  explanation  in  both  cases  was  a  local  inflam- 
matory process  involving  the  wall  of  the  vessels,  producing  a  weakness 
and  subsequent  rupture.  In  both  cases  the  hemorrhage  was  into  the 
brain  substance  and  in  the  distribution  of  the  lenticulostriate  artery. 


SUBDURAL  HEMORRHAGE. 

When  the  hemorrhage  occurs  at  birth  the  child  is  either  born  dead 
or  in  a  condition  of  asphyxia.  In  rare  cases  it  mav  be  very  pale.  If 
artificial  respiration  be  performed  and  vitality  returns  definite  symptoms 
are  manifested  and  the  child  may  die  in  the  course  of  a  week  or  recover 
with  evidence  of  marked  disturbance  of  cerebral  function.  The  cyanosis 
usually  persists,  the  temperature  is  subnormal,  somnolence  is  present, 
in  fatal  cases  gradually  passing  into  coma.  Convulsions  are  present,  but 
are  rarely  generalized,  and  are  fre(juently  limited  to  the  eyes  and  to  the 
face;  sometimes  an  arm  or  even  a  whole  side  is  involved*  If  the  child 
lives  sufficiently  long,  contractures  develop.     Persistent  vomiting  and 


DISEASES  OF  THE  BRAIN  955 

retention  of  the  intestinal  contents  are  observed  in  the  early  cases.  Par- 
alysis is  rarely  met  with  in  early  infancy  due  to  hemorrhage.  The  child 
usually  dies  before  the  end  of  a  week,  but  the  symptoms  may  persist 
for  several  weeks,  and  where  the  hemorrhage  is  slight  recovery  may  take 
place. 

When  the  destruction  of  brain  tissue  or  the  pressure  on  the  brain 
interferes  with  its  development,  atrophy  or  sclerosis  of  the  brain  may 
result,  leading  to  one  of  the  cerebral  atrophies  of  childhood.  (See  Cere- 
bral Palsies  of  Childhood.) 

Diagnosis.— The  diagnosis  depends  upon  a  knowledge  of  the  etiological 
factors  at  play  during  birth,  and  the  presence  in  the  newborn  after  a 
difficult  labor  of  marked  cyanosis,  subnormal  temperature,  and  con- 
vulsions. The  only  other  condition  from  which  subdural  hemorrhage 
may  be  diagnosed  is  tetanus  neonatorum.  The  absence  of  cyanosis 
and  of  difficult  labor  and  the  presence  of  the  tetanus  bacillus  in  the 
umbilical  cord  would  make  a  diagnosis. 

Treatment. — Artificial  respiration  should  be  used  to  overcome  the  im- 
mediate effects  of  the  hemorrhage,  and  heat  and  mild  stimulation  em- 
ployed.to  assist  in  controlling  the  shock.  Surgical  procedures  in  com- 
petent hands  has  given  fair  results  in  a  small  number  of  cases.  The 
removal  of  the  clot  should  not  be  attempted  until  the  strength  of  the 
child  is  such  as  to  stand  the  shock  of  a  serious  operation,  but  the  after- 
results  of  hemorrhage  are  so  serious  that  this  method  of  treatment  should 
be  tried  more  frequently.  Attention  should  here  be  called  to  the  results 
of  the  use  of  forceps  in  the  production  of  cerebral  traumatism.  In  cases 
of  difficult  or  prolonged  labor,  hemorrhages  into  the  cerebral  meninges 
may  occur  in  the  childbearing  process,  and  this  may  account  to  a 
limited  extent  for  the  cerebral  disorders  which  occur  in  a  large  percent- 
age of  cases  of  forceps  delivery.  It  should,  however,  be  borne  in  mind 
that  traumatism  to  the  infant  brain  from  careless  use  of  instruments 
is  likely  to  give  rise  to  serious  after-effects.  A  normal  or  even  some- 
what prolonged  childbearing*  process  should  not  be  interfered  with 
merely  to  reduce  the  pain  or  discomfort  to  the  mother.  While  the  ap- 
plication of  instruments  to  assist  in  delivery  of  the  head  may  be  a  good 
routine  procedure  in  normal  cases  in  the  hands  of  expert  and  careful 
obstetricians,  I  feel  quite  confident  that  the  natural  process  of  child- 
bearing  is  altogether  the  safest  for  the  integrity  of  the  cerebral  tissues. 
Children  with  defective  or  retarded  mental  development  (conditions 
which  do  not  attract  the  attention  of  parents  until  late  childhood  and 
to  which  the  attention  of  the  obstetrician,  as  a  rule,  is  "never  called), 
give  so  frequently  in  our  clinics  a  history  of  instrumental  delivery,  that 
great  care  should  be  used  in  clinics  in  which  the  forceps  is  used  as-  a 
routine  measure  to  study  the  effects  of  this  procedure  on  the  cerebral 
tissues  in  later  childhood  instead  of  being  satisfied  with  immediate  re- 
sults after  delivery.  Where  the  use  of  forceps  is  clearly  indicated,  they 
should  be  used  promptly,  and  with  careful  attention  to  the  prevention 
of  too  much  pressure  on  the  head.  Delay  in  their  use  may  be  as 
serious  for  the  integrity  of  the  cerebral  tissues  as  careless  application 


956  DISEASES  OF  THE  NERVOUS  SYSTEM 

in  cases  where  they  are  not  indicated,  and  where  the  life  of  the  child 
and  the  integrity  of  the  cerebral  tissues  is  not  taken  into  as  much  con- 
sideration as  the  comfort  of  the  mother. 


CEREBRAL  HEMORRHAGE. 

Hemorrhage  into  the  brain  substance  is  closely  associated  with  the 
infectious  fevers.  The  position  of  the  hemorrhage  corresponds  to  that 
seen  in  the  adult.  The  lenticular  nucleus  is  usually  the  seat  of  the 
hemorrhage,  with  pressure  on  or  destruction  of  the  internal  capsule  and 
sometimes  involvement  of  the  optic  thalamus.  Hemorrhage  into  the 
cerebellum  may  occur.  Hemorrhage  into  the  ventricles  is  of  frequent 
occurrence  in  early  infancy,  and  may  occur  during  birth.  It  is  some- 
times the  result  of  an  infiltrating  subarachnoidal  hemorrhage  into  the 
ventricles  through  the  transverse  fissure,  or  it  may  be  due  to  the  rupture 
of  one  of  the  vessels  of  the  choroid  plexus  or  of  a  vein  immediately 
beneath  the  ependymal  lining  of  the  ventricle. 

Symptomatology. — The  symptoms  produced  by  hemorrhage  into  the 
braiu  substauce  varies  greatly  in  infancy  and  childhood;  in  late  child- 
hood they  do  not  (lifter  essentially  from  those  seen  in  the  adult.  There 
is  a  sudden  apoplexy;  the  child  falls  to  the  floor  unconscious,  with 
relaxation  of  the  body  and  complete  loss  of  tonicity  on  the  paralyzed 
side.  The  pupils  are  usually  dilated  and  may  be  equal  or  unequal,  but 
during  the  unconscious  period  do  not  react  to  light.  In  hemorrhages 
into  the  ventricles  the  pupils  are  contracted;  there  are  persistent  and 
prolonged  coma  and  convulsions.  The  temperature  is  normal  and  may 
be  subnormal  on  the  affected  side.  The  unconsciousness  may  last  only 
a  few  hours  or  may  be  prolonged  in  ventricular  or  extensive  hemorrhage 
for  days  or  until  death  takes  place.  As  consciousness  returns  the  left 
side  of  the  body  is  found  to  be  paralyzed,  including  the  lower  portion 
of  the  face,  the  arm,  and  the  leg.  The  reflexes  which  had  disappeared 
during  the  unconscious  period  are  now  present  and  increased.  After 
a  varying  period,  depending  on  the  extent  of  disturbance  of  the  motor 
fibres,  sufficient  power  retiu-ns  to  enable  the  child  to  walk  by  dragging 
the  paralyzed  leg.  The  return  of  power  develops  first  in  the  leg  and 
later  in  the  arm  and  face.  The  muscles  employed  in  the  finer  and  more 
complex  movements  remain  paralyzed.  When  hemorrhage  occurs  in 
the  cerebellum  the  patient  presents  a  cerebellar  ataxic  gait  (see  p.  950), 
with  nystagmus,  clumsiness  of  motion  on  the  affected  side,  with  or 
without  loss  of  power. 

\'entricular  hemorrhage  is  usually  fatal.  The  unconsciousness  is 
prolonged  and  convulsions  persistent. 

In  infancy  and  early  childhood  the  hemorrhage  may  be  latent  with 
an  increasing  coma;  or  be  associated  (in  the  majority  of  cases)  with  con- 
vulsions, contractures,  and  partial  or  complete  paralysis.  It  is  usually 
fatal,  and  if  recovery  takes  place,  an  atrophic  paralysis  on  the  opposite 
side  of  the  body,  with  aphasia  in  left-sided  lesions  is  present. 


DISEASES  OF  THE  BRAIN  957 

Diagnosis. — In  infancy  hemorrhage  of  the  brain  cannot  often  be 
differentiated  from  other  forms  of  intracranial  hemorrhage.  In  child- 
hood a  sudden  onset  with  unconsciousness,  complete  flaccidity  of  one 
side  of  the  body,  and  a  persistent  hemiplegia  following  the  more  severe 
infectious  fevers  will  make  the  diagnosis  of  cerebral  hemorrhage.  Cere- 
bral embolism  may  give  the  same  group  of  symptoms,  but  consciousness 
may  not  be  lost,  and  there  is  usually  a  source  for  the  embolus  in  disease 
of  the  left  heart. 

Treatment. — "When  the  hemorrhage  occurs  the  child  should  be  placed 
on  its  back  or  on  the  non-paralyzed  side,  with  the  head  somewhat 
elevated.  If  the  pulse  is  full  and  the  face  is  flushed  or  cyanosed  vene- 
section may  be  done,  "^ith  the  withdrawal  of  sufficient  blood  to  produce 
a  depressing  effect  on  the  pulse.  The  relief  to  the  high  tension  of  the 
circulation,  if  secured  early,  will  prevent  further  bleeding  into  the  brain. 
Free  purgation  is  indicated,  and  this  may  be  secured  by  a  drop  of  croton 
oil  on  the  tongue.  The  administration  of  0.324  gm.  (5  gr.)  of  bromide 
of  sodium  and  of  the  same  dose  of  chloral  hydrate  by  rectum  should  be 
given  for  the  convulsions.  Bromides  should  also  be  given  if  the  child 
is  restless.  Care  should  be  used  in  the  administration  of  cardiac  stimu- 
lants on  account  of  the  possibihty  of  producing  further  hemorrhage. 


CEREBRAL  ATROPHIC  PALSIES. 

Quite  a  large  number  of  cases  come  under  the  observation  of  those 
dealing  with  diseases  of  children,  of  spastic  paralysis  of  cerebral  origin. 
In  all  such  cases  a  pathological  process  in  very  early  life  leads  to  exten- 
sive disease  of  one  or  both  of  the  cerebral  hemispheres.  "While  the  symp- 
tomatology^ varies  considerably,  the  clinical  picture  is  distinct  and  easily 
recognized.  Three  separate  groups  depending  upon  the  extent  of  motor 
involvement  are  seen: 

1.  Cerebral  Spasiic  Hemiplegia. — This  is  due  to  involvement  of  at  least 
the  motor  area  of  one  cerebral  hemisphere. 

2.  Cerebral  spastic  quadriplegia,  or  diplegia,  as  it  is  frequently  called, 
in  which  all  four  extremities  are  involved  and  due  to  bilateral  movement 
of  the  brain. 

3.  Cerebral  spastic  paraplegia,  in  which  the  legs  alone  are  involved, 
due  to  involvement  of  the  vertex  of  the  brain,  affecting  the  leg  centres 
which  lie  close  together  on  either  side  of  the  superior  median  fissure 
of  the  brain. 

In  any  of  the  above  groups  the  lesion  may  involve  areas  of  the  brain 
other  than  the  motor  areas,  with  the  production  of  sensory,  special  sense, 
or  psychic  manifestations. 

Etiology. — The  cerebral  atrophies  of  childhood,  as  their  name  indicates, 
are  essentially  manifestations  of  disturbance  of  cerebral  function  occur- 
ring very  early  in  fife.  The  intensity  of  the  psychic  and  other  mani- 
festations, with  involvement  of  only  a  small  portion  of  the  brain  mass, 
is  due  to  the  occurrence  of  the  cerebral  insult  at  a  period  when  the 


968  DISEASED  OF  THE  NERVOUS  SYSTEM 

cortical  cells  have  not  yet  assumed  their  normal  function.  Cortical  cells 
may  assume  under  abnormal  circumstances,  sucii  as  the  presence  of 
free  blood,  degenerating  brain  substance,  etc.,  a  metabolic  function,  and 
in  this  way  lose  that  function  for  which  they  were  primarily  intended. 
I  have  seen  the  cortical  cells  giving  a  pure  hemoglol)in  reaction  where 
the  presence  of  free  blood  necessitated  its  removal  from  the  tissues. 
I  have  also  seen  a  condition  of  the  nerve  cells  years  after  the  pri- 
mary disturbance  of  function  in  such  a  condition  of  degeneration  as  could 
only  be  explained  by  some  such  original  perversion  of  function.  A  certain 
number  of  cases  may  be  explained  by  prenatal  ])athological  processes, 
such  as  in  the  two  cases  of  my  own  mentioned  under  IMeningeal 
Hemorrhage,  in  the  cases  reported  by  Osier  in  the  brain  of  the  fetus, 
the  mother  of  which  died  of  typhoid  fever  about  the  sixth  month  of 
pr(>gnancy,  and  in  a  case  of  Cotard,  following  an  injury  to  the  mother, 
The  effect  of  syphilis  and  alcoholism  in  the  parents  interfering  with  the 
proper  development  of  the  central  nervous  system  has  been  suggested. 
It  i."^,  however,  nuich  more  likely  that  a  diseased  condition  of  the  vessels 
due  to  these  causes  is  a  more  })()tent  factor.  Osier  reports  a  case  follow- 
ing ligature  of  the  carotid. 

The  majority  of  cases  undoubtedly  result  from  some  disturbance  of 
cerebral  function  at  birth  or  shortly  after  birth.  A  prolonged  or  difficult 
labor,  and  especially  where  this  is  associated  with  the  use  of  instruments 
or  rec|uiring  version,  is  an  important  etiological  factor.  Such  a  history 
was  ()f)tained  in  177  of  the  400  cases  reported  by  Starr.  Where  only  one 
child  in  the  family  is  affected  it  is  usually  the  eldest,  and  the  history 
given  is  that  the  labor  was  much  more  prolonged  and  difficult  than  that 
of  the  subsequent  children.  The  history  of  a  blue  baby,  with  or  without 
convulsions,  and  the  evidence  of  the  malformed  head  of  large  numbers 
of  these  children,  suggests  the  occurrence  of  meningeal  or  cerebral 
hemorrhage  at  the  time  of  birth. 

Traumatism  to  the  mother  and  that  due  to  the  childbearing  jn-ocess 
itself  are  not  infre(|uent  causes  of  cerebral  hemorrhage.  I  have  seen 
extensive  cerebral  hemorrhage  practically  destroying  the  entire  hemi- 
sphere as  the  result  of  a  fall  on  the  head.  Twenty-two  of  Starr's  cases 
gave  a  history  of  severe  falls  during  infancy. 

In  cases  developing  some  time  after  birth  the  disturbance  of  cerebral 
function  may  have  had  its  origin  at  birth  or  as  the  result  of  some  patho- 
logical process  during  early  childhood.  Injury  to  the  soft  brain  tissues 
during  the  childbearing  process  may  not  be  so  great  as  to  cause  extensive 
hemorrhage,  and  yet  may  be  sufficiently  severe  by  the  production  of 
small  capillary  hemorrhages  or  by  pressure,  as  to  result  in  the  production 
of  symptoms  when  the  child  has  reached  an  age  when  the  function  of 
the  cortical  areas  are  required  or  when  they  would  first  attract  the 
attention  of  parents.  There  is  no  doubt  that  extensive  inflammatory 
and  toxic  processes  affecting  the  l^rain  may  be  the  result  of  the  acute 
infections,  such  as  pneumonia,  scarlet  fever,  measles,  diphtheria,  or 
typhoid.  In  whooping-cough  passive  venous  congestion  during  a  spasm 
of  coughing  may  lead  to  the  rupture  of  a  vessel  in  the  brain.    Rhein  has 


DISEASES   OF  THE  BRAIN  <J59 

recently  reported  a  diffuse  encephalitis  due  to  whooping-cough.  This 
condition  may  also  obtain  as  a  result  of  convulsions,  but  it  is  always 
difficult  if  not  impossible  to  determine  whether  the  hemorrhage  was  the 
result  of  the  convulsion  or  vice  versa. 

Heredity  plays  an  important  role.  The  heredity  is  not  a  direct 
heredity,  but  the  presence  of  epilepsy,  insanity,  grave  hysteria,  or  neuras- 
thenia in  the  parents. 

Pathology. — Lesions  found  at  autopsy  in  the  majority  of  cases  can  be 
traced  directly  or  indirectly  to  some  disturbance  of  the  circulation^ 
i.  e.,  cerebral  or  meningeal  hemorrhage,  cyst  formation,  thrombosis,  or 
embolism.  In  the  other  cases  a  sclerosis  with  atrophy  as  a  result  of  an 
inflammation  of  the  brain  or  of  the  meninges  or  both;  hydrocephalus 
with  adhesions  at  the  base,  or  as  a  result  of  inflammation  of  the  lining 
of  the  ventricles,  and  atrophy  of  the  brain  from  pressure  by  cystic  con- 
ditions of  the  meninges  or  depressed  bone  have  been  found.  In  all 
cases  independent  of  the  primary  cause  an  atrophy  of  a  part  or  of  the 
entire  brain  with  primary  or  secondary  sclerosis  results.  Any  part  of 
the  brain  may  be  affected.  In  lesions  purely  of  vascular  origin,  as 
thrombosis,  embolism,  etc.,  the  motor  area  in  the  region  of  Rolando 
and  the  cortex  in  its  immediate  neighborhood  is  most  frequently  involved. 
Porencephaly  (a  condition  in  which  a  cyst  or  cysts  occupy  the  cerebral 
hemisphere)  is  found  in  the  largest  number  of  cases,  as  was  observed 
in  132  of  the  343  collected  by  Starr.  Whether  this  condition  was  pri- 
marily of  vascular  origin  or  due  to  simple  failure  of  development  could 
not  be  determined.  The  frequency  of  the  other  lesions  in  Starr's  cases 
are  as  follows:  sclerotic  atrophy  as  a  terminal  result  of  encephalitis, 
97  cases;  maldevelopment  (failure  of  development  of  the  cortical  cells), 
32  cases;  vascular  atrophy,  23  cases;  meningoencephalitis,  21  cases; 
cysts,  14  cases;  intracranial  hemorrhage,  18  cases;  hydrocephalus,  5 
cases. 

Not  infrequently  circumscribed  lesions  are  associated  with  a  failure 
of  full  development  of  the  rest  of  the  brain,  and  a  condition  of  micro- 
cephaly results.  In  the  hydrocephalic  cases  the  skull  may  be  larger 
than  normal ;  not  infrecjuently  the  dome  of  the  skull  on  the  normal  side 
is  of  full  normal  contour,  while  that  covering  the  atrophic  hemisphere 
is  smaller  and  more  sloping. 

Symptomatology.  Cerebral  Spastic  Hemiplegia. — When  the  cerebral 
injury  occurs  at  birth  or  before  birth  the  symptoms  are  present  from 
birth.  Where  the  cerebral  disease  is  not  extensive  the  symptoms  may 
not  be  noticed  for  several  months.  When  the  cerebral  traumatism  is 
marked  at  birth,  the  presence  of  convulsions,  cyanosis,  and  unconscious- 
ness directs  the  attention  to  the  loss  of  power  and  spasticity  early  in 
infancy. 

In  cases  developing  some  time  after  birth,  due  to  thrombosis,  embolism, 
or  as  a  result  of  a  slowly  developing  sclerosis  secondary  to  traumatism 
at  birth,  which,  however,  may  not  be  manifested  by  distinct  symptoms 
at  that  time,  the  onset  is  associated  with  general  convulsions  and  uncon- 
sciousness.    There  may  be  only  one  or  two  convulsions  or  a  series  of 


960  DISEASES  OF  THE  NERVOUS  SYSTEM 

convulsions,  with  prol()n(i;e(l  iiiuonsciousiicss  lasting  over  an  entire  day  or 
even  several  days.  The  convulsions  are  often  d(\serihed  by  the  mother 
as  inward  spasms — i.  c,  where  the  tonic  rigidity  of  the  body  in  the 
unconscious  period  is  associated  with  slight  or  periodic  clonic  con- 
vulsions. 

The  convulsions  in  some  cases  recur  at  varying  intervals,  the 
paralvsis  developing  either  immediately  after  the  first  seizure  or 
after  one  of  the  subsefjuent  attacks.  It  may  be  progressive,  increasing 
after  each  attack.  The  paralysis  at  first  is  a  flaccid  paralysis,  but  it  may 
be  spastic  from  the  beginning.  The  lower  face,  arm,  and  leg  are  at  first 
completely  paralyzed,  but  as  the  child  grows  sufficient  power  returns 
to  enable  it  to  walk,  and  in  a  few  cases  return  of  power  in  the  leg  may 
be  almost  complete.  In  the  vast  majority  of  cases  the  loss  of  power 
remains  very  marked,  and  is  associated  with  decided  rigidity  and  some 
contracture  at  the  knee.  This  gives  rise  to  a  distinct  spastic  gait,  with 
dragging  of  the  toe  and  a  rotatory  movement  of  the  body  to  swing  the 
palsied  leg  forward.  There  is  less  return  of  power  in  the  arm,  which 
may  be  completely  useless  either  from  the  paralysis  or  more  frequently 
from  the  secondary  rigidity  which  keeps  the  arm  flexed  at  the  elbow, 
the  hand  flexed  on  the  arm,  and  the  fingers  tightly  closed  in  the  palms. 
But  even  in  the  cases  where  there  is  a  fair  return  of  power,  and  where 
the  contractures  are  not  very  marked,  certain  other  associated  motor 
phenomena  may  seriously  interfere  with  the  use  of  tliis  member.  There 
is  often  a  lack  of  volitional  control;  when  an  attempt  is  made  to  extend 
the  arm  an  involuntary  flexor  movement  results.  When  an  attempt  is 
made  to  use  the  arm  of  the  sound  side,  an  involuntary  associated  move- 
ment of  a  like  character  develops  in  the  paralyzed  arm  and  interferes 
with  bimanual  operations.  In  a  large  number  of  cases  (about  one- 
fourth  of  Osier's  series)  a  rhythmic  tremor,  which  may  be  very  fine  or 
very  coarse;  a  gross,  inco-ordinate  choreiform  movement  of  an  intention 
type  or  a  slow,  constant,  snake-like  movement  of  the  fingers  and  arm, 
due  to  alternate  contractions  of  diflferent  groups  of  muscles  (athetosis), 
which  seriously  interfere  with  the  use  of  the  arm  and  often  cause  extreme 
annoyance  and  discomfort  may  be  present.  The  paralysis  of  the  lower 
face  is  frecjuently  associated  with  contracture,  and  this,  together  with  the 
failure  of  development  of  the  skull  on  the  affected  side,  produce  a 
marked  asymmetry.  Athetoid  movements  about  the  mouth  may  be 
present. 

The  paralyzed  side  fails  to  keep  pace  with  the  growth  of  the  opposite 
side,  and  in  later  childhood  the  extremities  are  much  shorter;  smaller, 
and  with  marked  loss  of  vasomotor  tone.  This  is  manifested  by  coldness, 
mottling,  or  considerable  cyanosis.  The  reflexes  on  the  paralyzed  side  are 
markedly  increased  and  are  associated  with  ankle  clonus  and  the 
Babinski  reflex.  ^Yhile  there  is  failure  of  development  of  the  affected 
side  there  is,  as  a  rule,  no  true  degenerative  atrophy.  The  electrical 
examination  gives  normal  reactions.  The  sensation  on  the  aflFected  side 
is  normal,  but  in  rare  cases  may  be  lost  when  the  cerebral  lesion  is  very 
extensive. 


DISEASES  OF  THE  BRAIN  961 

Aphasia  is  present  in  the  majority  of  cases  when  the  lesion  is  on  the 
left  side  of  the  brain  and  there  is  a  right  hemiplegia.  It  is  usually 
motor  in  type,  the  child  merely  being  unable  to  talk,  although  it  may 
be  able  to  understand  what  is  said  to  it  and  may  learn  to  read  and 
write. 

As  the  child  grows  it  often  recovers  the  faculty  of  speech,  probably 
through  the  right  brain  taking  up  this  function. 

Epilepsy  is  of  very  frequent  occurrence  and  develops  in  the  majority 
of  cases  shortly  after  the  onset  of  paralysis,  but  may  be  delayed  for 
months  or  even  years.  It  should  be  borne  in  mind  that  the  weakened 
nervous  system  of  such  children,  and  even  as  late  as  adult  life,  is  very 
prone  to  reflex  disturbances  through  peripheral  irritation,  or  manifests 
disturbance  very  easily  from  intoxication.  The  epileptic  manifestations 
vary  greatly.  They  are  of  frequent  occurrence  and  more  intense  than 
in  the  essential  epilepsies.  There  may  be  simply  petit  mal,  partial 
epilepsy  beginning  in  an  extremity  and  either  localized  there  or  extend- 
ing to  the  rest  of  the  body,  and  associated  with  or  without  loss  of  con- 
sciousness, or  they  may  be  general  convulsions  presenting  the  clinical 
picture  of  essential  epilepsy.  Temporary  paralysis  in  the  afl^ected 
extremities  may  follow  the  local  or  general  convulsion.  Either  as  a 
result  of  the  frequent  epileptic  attacks  or  more  frequently  as  a  result 
of  the  brain  lesion  there  is  presented  a  decided  mental  weakness. 

Mental  Defect. — This  is  one  of  the  most  marked  and  distressing 
symptoms  of  this  disease.  All  grades  of  mental  defect  from  a  slight 
lowering  of  the  intelhgence  to  complete  idiocy  are  seen.  Idiocy  or 
complete  lack  of  intelligence,  with  inabiUty  to  acquire  ideas,  may  be 
present  from  the  beginning.  This  is  most  common  in  those  cases  dating 
from  birth  or  very  shortly  after  birth.  In  other  cases  imbecility  or  the 
inability  to  acquire  other  than  the  simplest  ideas  is  frequently  met  with. 
In  a  large  number  of  cases  survi\ing  early  childhood  there  is  a  con- 
dition merely  of  weak-mindedness  or  retarded  development.  Some 
cases  show  apparently  normal  mental  power,  but  are  unable  to  stand 
the  stress  of  advanced  education,  and  when  tliis  is  persisted  in,  develop 
grave  neurasthenia,  hysteria,  persistent  headaches,  or  insanity.  Such 
children  are  often  irascible,  of  violent  temper,  and  frequently  manifest 
a  tendency  to  purposeless  cruelty  to  animals  or  other  children,  and  of 
destruction  of  inanimate  objects. 

Lesions  near  the  motor  area,  but  invohing  it  only  by  irritation,  may 
produce  very  httle  loss  of  power,  but  slight  or  irritative  motor  symptoms. 
Thus  an  increased  tonicity  of  the  muscles  on  the  affected  side  produces 
clumsiness  or  a  tendency  to  athetoid  movements  only  when  voHtional 
movements  are  attempted.  In  other  cases  an  athetosis  may  be  very 
marked,  with  comparatively  little  loss  of  power. 

^Yhen  the  temporosphenoidal  lobe  is  affected  on  the  left  side  in 
association  with  involvement  of  the  motor  area,  deaf-mutism  may  result. 
In  a  boy  of  twelve  vdih  marked  spastic  hemiplegia  there  was  deaf- 
mutism."^  He  could  not  understand  what  was  said  to  him,  but  could  hear 
and  understand  the  significance  of  the  signal  bell  at  the  school.  This 
61 


962  DlSEASEii  OF  THE  NERVOUS  SYSTEM 

hov,  ill  spite  of  frefiuent  epileptic  attacks,  was  of  fair  intelligence  but  of 
verv  violent  temper. 

When  the  oeeipital  lobe  is  involved  hemianopsia  may  be  present  in 
association  with  hemiplegia.  Total  blindness  is  sometimes  present. 
This  may  be  tlue  to  lack  of  development  of  the  optic  nerve  or  defective 
development  of  the  cortex  in  the  oeeipital  area. 

Cerehral  Spastic  Quadriplegia. — In  this  grouj)  idl  four  extremities 
are  affected.  It  is  invariai)ly  a  condition  dating  from  birth,  and  the 
clinical  picture  presented  is  the  same  as  that  above  described  under 
Hemiplegia,  with  a  bilateral  involvement  instead  of  unilateral  involve- 
ment. It  results  from  extensive  injury  to  tiie  brain,  afFecting  both 
hemispheres.  In  severe  cases  there  is  rigidity  and  contractures  of  the 
extremities,  with  rigidity  of  the  back  and  neck  muscles  early  in  infancy, 
and  if  the  child  lives  it  remains  a  bedridden  idiot.  In  less  severe  cases 
the  child  learns  to  walk,  but  the  contractures  and  the  athetoid  move- 
ments give  a  peculiar,  shuffling,  clownish  element  to  the  gait,  which 
usuallv  excites  ridicule.  In  the  mild  cases  there  is  spasticity  of  the  gait 
and  a  certain  rigidity  and  clumsiness  of  arm  movement,  which  in  some 
cases  improves  as  the  child  grows  older,  and  in  other  cases  grows 
steadilv  worse.  In  the  severe  cases  idiocy  or  imbecility  is  the  invariable 
rule.  Distinct  and  definite  mental  deficiency  is  present  in  all  cases. 
Convulsions,  ^^olent  attacks  of  temper,  and  even  maniacal  outbreaks, 
aphasia,  and  irritative  motor  disturbances  are  more  frecpiently  present 
in  this  group  than  in  the  hemiplegias.  All  grades  of  motor  speech 
disturl)ances,  from  slight  stammering  to  complete  motor  aphasia,  are 
seen.  Not  infrecjuently,  in  training  children  who  stammer  and  stutter, 
cases  are  met  with  in  which  a  clumsy,  awkward  method  of  elevating 
the  arms  to  carry  out  the  breathing  exercises  attracts  the  attention,  and 
on  careful  examination  they  often  give  a  history  of  traumatism  at  birth, 
some  rigidity  of  the  muscles  leading  to  the  clumsiness  and  increase  of 
the  reflexes.  As  a  rule  they  are  backward  children,  who  have  not  sufficient 
mental  jx)wer  to  keep  pace  with  normal  children  of  their  own  age  in 
the  public  schools. 

A  diseased  condition  very  closely  resembling  tiiis,  but  flue  to  defective 
development  of  the  motor  tracts,  with  symptoms  of  abiotrophy,  has  been 
described  on  page  914;  but  in  these  children  the  manifestations  are 
purely  motor,  with  rigi(hty,  contractures,  loss  of  power,  and  increased 
reflexes,  but  with  no  e^^dence  of  cerebral  disturbance.  These  children 
are  as  l)right  intellectually  as  other  children.  There  is  no  history  of 
traumatism  or  of  difficult  labor  or  of  other  evidence  of  cerebral  insults 
at  any  time  in  the  history  of  the  child.  Several  children  of  the  same 
family  are  sometimes  affected. 

Cerebral  Spa.s-tic  Paraplegia. — In  this  group  the  lower  extremities 
alone  are  aftVcted.  The  lesion  is  confined  to  the  apex  of  the  brain, 
affecting  both  leg  centres  or  the  filires  originating  therein.  The  trauma- 
tism is  localized  and  in  most  cases  of  vascular  origin  due  to  hemorrhage, 
or  in  connection  with  lesion  of  the  superior  longitudinal  sinus  or  branches 
of  the  anterior  cerebral  arterv  (the  arm  and  face  centres  on  either  side 


DISEASES   OF  THE  BRAIN  963 

are  supplied  by  branches  from  the  middle  cerebral).  The  same  history 
of  difficult  or  prolonged  labor,  followed  early  in  childhood  by  a  spastic 
weakness  or  paralysis  of  the  lower  extremities,  without  loss  of  sensation, 
disturbance  of  the  bladder  or  rectum,  and  with  some  mental  deficiency, 
and,  in  some  cases,  with  epilepsy,  is  presented.  This  should  be  differ- 
entiated from  spinal  lesions  w^here  there  is  disturbance  of  sensation  up 
to  the  point  of  lesion,  involvement  of  the  bladder  and  rectum,  disease 
of  the  spine  itself,  with  normal  intelligence,  and  without  epileptic 
attacks.     (See  p.  897.) 

Diagnosis. — Any  one  of  the  above  groups  is  easily  recognized  by  the 
history  of  the  onset  in  early  childhood,  the  distribution  in  a  hemiplegic, 
quadriplegic,  or  paraplegic  form  of  paralysis,  spastic  type,  with  increased 
reflexes,  lack  of  sensory  disturbance,  mental  deficiency,  and  epileptic 
seizures. 

From  acute  anterior  poliomyelitis,  whether  affecting  both  lower 
extremities  or  an  arm  and  leg  of  the  same  side,  the  diagnosis  can  be 
easily  made  by  the  history  of  an  acute  onset,  with  a  flaccid  type 
of  paralysis,  loss  of  the  reflexes,  and  reactions  of  degeneration  in  the 
paralyzed  muscles,  and,  later,  by  the  atrophy  in  the  muscles  affected. 
In  these  cases  there  is  no  aphasia,  no  mental  deficiency,  and  no  epilepsy. 

High  spinal  lesions  producing  paralysis  of  all  four  extremities,  due  to 
fracture  or  dislocation  at  birth,  Pott's  disease  after  birth,  myelitis, 
tumor  of  the  cord,  or  hemorrhage  into  the  cord,  may  be  differentiated 
from  the  cerebral  spastic  quadriplegia  by  the  evidence  of  disease  of 
the  bone,  either  by  direct  examination  or  by  means  of  the  a^-ray;  by  the 
sensory  disturbance  below  the  point  of  lesion,  the  involvement  of  the 
bladder  and  rectum,  and  the  absence  of  cerebral  symptoms. 

Prognosis. — The  prognosis  in  the  vast  majority  of  cases  in  unfavorable. 
Apart  from  the  motor  disturbances — paralysis,  epilepsy,  etc. — which 
incapacitate  for  manual  work,  the  mental  deficiency  is  such  as  to  either 
relegate  the  sufferer  to  an  insane  asylum  or  institution  for  feeble-minded 
chilclren.  If  less  marked  it  incapacitates  liim  for  serious  mental  work, 
and  renders  him  dependent  on  others  for  care  and  support.  A  very  few 
cases  are  able  to  pass  through  a  common-school  education,  and  even  in 
rare  instances  successfully  take  up  a  college  training  and  assume  the 
duties  of  professional  work,  but  the  experiment  is  always  a  dangerous 
one  on  account  of  the  tendency  to  develop  under  stress  some  serious 
neurosis — epilepsy,  insanity,  neurasthenia,  etc.  The  motor  paralysis 
is  not  only  persistent  in  all  but  a  few  cases,  but  often  develops  with 
advancing  age.  Where  the  cerebral  traumatism  is  slight  improvement 
may  occur.    The  epilepsy  of  this  disease  rarely  yields  to  treatment. 

Treatment. — In  the  severe  cases  treatment  is  of  little  avail.  Sooner  or 
later  it  is  necessary  to  send  the  patients  to  a  home  for  the  feeble-minded 
or  to  an  asylum.  Where  a  moderate  amount  of  intelligence  is  present, 
they  are  best  treated  in  special  training  schools  for  the  feeble-minded 
under  the  care  of  expert  and  skilled  teachers.  Where  the  intelligence 
approaches  normal,  the  education  of  the  child  should  be  very  carefully 
guarded;  better  under  indi\idual  teachers  than  in  large  classes  where 


964  DISEASES  OF  THE  NERVO  US  SYSTEM 

the  stress  to  keep  pace  with  normal  iniiul.s  may  work  serious  conse- 
quences. The  hick  of  moral  tone  in  many  of  these  children,  often 
amounting  to  criminal  propensities,  also  interferes,  with  too  close  asso- 
ciation with  other  children.  Parents  too  often,  I  might  say  almost 
invariably,  lavish  an  affection,  care,  and  expenditure  on  these  deficients 
entirely  disproportionate  to  the  results  which  may  reasonably  be  expected, 
and  often  to  the  exclusion  and  harm  of  their  normal  and  deserving 
children,  to  be  repaid,  even  in  those  cases  who  stand  education  well 
by  ingratitude  and  often  disgrace.  A  quiet,  simple  life  in  a  country 
home,  with  proper  nutrition  and  well<lirected  discipline,  gives  by  far 
the  best  results. 

Contractures  may  be  prevented  and  the  use  of  the  paralyzed  limbs 
improved  by  intelligent  massage  and  passive  movements.  Where 
contractures  have  occurred,  section  of  tendons  not  only  relieves  the 
deformity  but  often  cures  painful  spasm  in  the  affected  muscle.  Ortho- 
pedic apparatus  is  useful  in  some  cases  in  maintaining  a  good  position 
and  to  prevent  increasing  deformities.  Its  usefulness  in  this  disease, 
however,  is  very  limited. 

The  history  of  surgical  procedures  directed  to  relieving  or  curing  the 
cerebral  condition  is  not  such  as  to  warrant  trephining  in  many  cases. 
I  have  never  seen  any  appreciable  residts.  When  acute  cerebral  hemor- 
rhage can  be  diagnosed,  and  especially  when  this  is  of  a  meningeal  type, 
operation  at  the  time,  on  account  of  the  hopeless  nature  of  the  sequela?, 
would  be  justified.  The  only  case  in  my  personal  experience  in  which 
this  was  done  the  result  was  imsatisfactory  on  account  of  the  death 
of  the  child,  and  no  conclusion  could  be  drawn  from  it.  In  later  child- 
hood, operation  is  only  justified  when  there  is  distinct  evidence  of  local 
pressure  on  the  brain  tissue.  These  cases  form  a  very  small  part  of 
the  number  coming  under  observation,  and  most  of  them  are  found  to 
be  due  to  cystic  conditions  of  the  meninges  and  of  the  cortex.  Even 
in  such  favorable  cases  it  is  very  exceptional  to  have  sufficient  relief  of 
symptoms  as  to  justify  an  operation.  The  best  result  that  can  be 
expected,  where  the  mental  condition  is  markedly  deficient,  is  to  raise 
the  grade  of  the  imbecility.  It  is  cpicstionable,  however,  inasmuch  as 
we  cannot  effect  a  cure,  whether  it  is  not  better  to  permit  these  unfortu- 
nates to  remain  as  near  intellectual  oblivion  as  possible,  instead  of 
elevating  them  to  an  appreciation  of  their  own  deficiency  and  suffering. 


HYDROCEPHALUS. 

In  dealing  with  this  subject  I  shall  only  consider  internal  hydro- 
cephalus: an  accumulation  of  fluid  in  the  ventricles  of  the  brain  causing 
pressure  on  the  brain  substance  when  the  skull  is  already  closed,  and 
producing  extension  of  the  skull,  separation  of  the  bones,  and  enlarge- 
ment of  the  head  when  it  occurs  in  infancy.  Internal  hydrocephalus 
may  be  either  a  general  internal  hydrocephalus,  with  distention  of  all 
the  ventricles,  or  a  partial  hydrocephalus  in  which  the  fourth  ventricle 


DISEASES  OF  THE  BRAIN  965 

is  not  involved.  Hydrocephalus  may  be  congenital  or  acquired.  Of  the 
acquired  form  we  have  to  deal  with  the  chronic  internal  hydrocephalus 
and  an  acute  internal  hydrocephalus— the  meningitis  serosa  of  Quincke. 
Acute  Internal  Hydrocephalus.  Etiology.— While  an  acute  internal 
hydrocephalus  is  a  frequent  accompaniment  of  tuberculous  and  other 
forms  of  meningitis,  it  is  occasionally  met  with  as  a  pathological  con- 
dition due  to  an  inflammation  localized  to  the  lining  membrane  of  the 
ventricles  and  of  the  choroid  plexus.  Quincke,  however,  considers  the 
acute  effusion  into  the  ventricles  as  comparable  to  the  serous  effusion 
into  the  skin  in  angioneurotic  edema.    In  a  series  of  experiments  which 

Pig.  197 


Hydrocephalus. 


I  carried  out  a  few  years  ago  into  the  nature  and  pathology  of  this 
affection,  the  results  confirmed  in  certain  respects  this  idea;  extensive 
inflammatory  lesions  of  the  ependyma  were  produced  without  hydro- 
cephalus. The  inflammatory  lesions  seen  in  the  ependyma  are  the 
resuh  of  a  toxic  condition  of  the  retained  fluid.  The  disease  is  more 
frequently  seen  in  late  childhood  and  adult  life,  and  frequently  in  those 
who  show  some  previous  hydrocephalus.     Traumatism  may  also  be 

Symptomatology.— The  symptoms  develop  acutely  with  slight  fever, 
which  gradually  ascends  for  several  days  and  then  slowly  drops  to  normal, 


966 


DISEASES  OF  THE  NERVOUS  SYSTEM 


and  after  a  short  intermission  is  again  followed  by  another  paroxysm 
whicli  may  be  repeated  several  times  throughout  the  eourse  of  the 
disease.  At  the  onset  there  is  evidenee  of  marked  increase  of  intra- 
cranial pressure.  Headache  develops  early,  and  is  associated  with 
choked  disk  and  l)lindness,  retraction  of  the  neck,  slowing  of  the  pulse, 
somnolence,  stupor,  <U>lirium,  and  coma.  Paralysis  of  the  cranial  nerves 
mav  be  present.  All  of  these  symptoms,  which  urc  most  int<>nse  with  the 
fastigium  of  the  fever,  subsid<',  and   may  entirely  disappear  when  the 


Fl(;.19.S 


Hydrocephalus  with  paralysis  of  both  extremities,  wrist-drop.  etc. 


temperature  drops  to  normal,  to  reappear  again  in  the  course  of  several 
days  or  a  week  with  reappearance  of  the  fever.  This  is  repeated  for 
several  paroxysms,  the  patient  either  becoming  progressively  weaker 
and  dying  with  symptoms  of  intense  intracranial  pressure,  or  the  suc- 
cessive paroxysms  decrease  in  intensity,  and  the  patient  goes  on  to 
convalescence  with  partial  or  total  blindness  and  weakened  mental 
power.  The  .symptoms  have  entirely  disappeared  after  lumbar  puncture, 
with  the  evacuation  of  a  large  cjuantity  of  fluid.  Ca.ses  have  been 
reported  lunning  an  afebrile  course  with  the  same  variations  in  symp- 


DISEASES   OF  THE  Bit  A  IN  I  967 

toms  and,  in  some  cases,  without  variation,  and  which  could  not  be 
differentiated  in  their  acute  form  from  brain  tumor.  Many  of  the 
rapid  recoveries  from  brain  tumor,  so  diagnosed,  may  belong  to  this 
category. 

Diagnosis. — The  diagnosis  from  meningitis  and  brain  tumor  may 
be  made  by  the  recurring  paroxysms  of  fever,  with  the  variations  of 
the  clinical  picture  during  the  febrile  and  afebrile  period.  The  absence  of 
a  causative  agent  in  the  cerebrospinal  fluid  and  the  relief  of  symptoms 
after  lumbar  puncture  also  point  to  hydrocephalus. 

Treatment. — The  treatment  is  that  of  meningitis,  with  the  use  of 
lumbar  puncture  as  a  therapeutic  agent.  In  the  case  reported  by  Dr. 
Burr  and  myself  from  the  Philadelphia  Hospital  the  variations  in  the 
symptoms,  and  their  almost  complete  absence  with  the  subsequent 
decline  of  fever,  led  us  to  postpone  any  radical  method  of  treatment. 
In  cases  where  lumbar  puncture  gives  negative  results,  tapping  of  the 
ventricles  should  give  good  results.  Prognosis  in  the  majority  of  cases 
is  unfavorable.  Evacuation  of  the  ventricular  fluid  in  all  but  a  very 
few  cases  gives  the  only  hope  for  relief  and  cure. 

Chronic  Internal  Hydrocephalus. — In  the  congenital  form  the  head 
is  enlarged  at  birth,  and  not  infrequently  gives  rise  to  difficult  labor,  and 
may  necessitate  surgical  procedure  to  deliver  the  child.  The  cause  of 
hydrocephalus  in  the  fetus  is  not  definitely  known.  The  changes  in  the 
choroid  plexus  and  the  ependyma  are  not  sufficient  to  account  for  the 
distention  of  the  ventricles.  Czerny  explains  this  condition  by  path- 
ological changes  found  in  the  adrenal,  and  wliich  he  thinks  causes  a 
disturbance  of  the  cerebral  circulation.  The  frequency  with  which 
spina  bifida,  defective  development  of  the  bones  of  the  spine,  polydactylia, 
webbing  of  the  fingers,  etc.,  are  found  in  children  with  hydrocephalus, 
would  lead  us  to  consider  it  a  structural  developmental  defect  rather 
than  the  result  of  a  local  process. 

In  the  acquired  form  inflammatory  lesions  obstructing  the  connection 
between  the  ventricles  of  the  brain  and  the  subarachnoid  spaces  or 
lesions  closing  the  aqueduct  of  Sylvius  are  found  in  a  small  percentage 
of  cases.  In  a  large  class  of  cases  there  is  no  obstructive  lesion  and 
nothing  is  found  to  account  for  the  hydrocephalus.  The  thickening  of 
the  ependymal  lining  of  the  ventricles  and  a  sclerotic  condition  of  the 
choroid  plexus  have  led  some  to  consider  the  hydrocephalus  the  result 
of  a  previous  inflammatory  disease  of  these  structures.  There  is,  how- 
ever, little  to  support  such  a  contention. 

The  accumulation  of  fluid  in  the  ventricles  may  be  enormous,  reaching 
several  pints.  The  brain  tissue  in  mild  cases  may  be  fairly  well  pre- 
served; in  severe  cases  it  may  be  represented  by  a  thin  band  of  tissue 
one-fourth  to  a  half-inch  in  thickness.  The  bones  of  the  skull  are  very 
thin,  with  separated  sutures;  or  when  union  has  taken  place  Wormian 
bones  are  found  in  them. 

Symptomatology. — In  the  minor  grades  of  hydrocephalus  the  only 
symptom  present  may  be  a  certain  grade  of  mental  deficiency.  While 
normal  intelligence  and  even  precocity  have  been  found  in  hydrocephalic 


968  DISEASES  OF  THE  NERVOUS  SYSTEM 

children,  they  are  certainly  very  rare;  and  while  I  have  seen  one  case  of 
such  intellifrence  as  to  enable  the  boy  to  take  a  college  deji^ree,  his  mental 
condition  was  certainly  not  one  to  be  envied.  The  child  learns  to  walk 
late,  if  at  all;  in  a  great  many  cases  a  spastic  type  of  paralysis  is 
present  from  the  beginning  or  develops  after  the  child  has  learned  to 
walk.  Epilepsy  is  present  in  a  large  number  of  cases.  The  course  of 
the  disease  is  more  or  less  progressive  in  early  life,  but  may  be  spon- 
taneously arrested  or  even  decidedly  improved  after  operative  proce(hu'es. 

Diagnosis. — The  diagnosis  is  merely  a  matter  of  observation.  The 
large,  globular  head  with  protruding  forehead,  small,  receding  face, 
deficient  mentality,  and  one  or  more  of  the  complications  referred  to, 
makes  the  diagnosis  easy.  The  diagnosis  from  the  rachitic  type  of  head 
need  only  be  mentioned. 

Treatment. — There  is  no  medicine  that  has  any  appreciable  effect 
in  causing  a  disappearance  of  the  fluid.  IMechanical  measures,  such  as 
the  use  of  cotnpressioii  l)y  adhesive  bands,  etc.,  are  no  longer  employed. 
Operative  })rocedures,  such  as  taj)})ing  the  ventricle  and  draining  into 
the  subdural  space  (Taylor)  sometimes  produce  good  results,  and  is 
being  tried  by  a  nimiber  of  careful  observers,  but  it  is  rare  that  a 
completely  normal  mental  condition  is  obtained. 


SECTION    XII. 
DISEASES  OF  THE  SKIN. 

By  CHARLES  TOWNSHEND   DADE,  M.D 


CHAPTER   XXXYIII. 

ECZE^IA— ERYTHEMA— URTICARIA— LMPETIGO— SCABIES. 

It  is  not  my  intention  to  study  all  of  the  diseases  of  the  skin  that 
may  be  seen  in  infancy  anfl  childhood,  but  to  present  merely  the  clinical 
characters  and  treatment  of  the  manifestations  that  most  often  fall 
under  the  notice  of  the  physician  who  is  called  to  treat  children.  For 
this  purpose  no  classification  is  necessary,  but  as  Eczema  is  the  most 
common  of  the  lesions  of  the  skin  it  will  be  first  described  and  then 
the  other  diseases  in  the  order  of  their  relative  importance. 


ECZEMA. 

Eczema  is  a  simple  exudative  inflammation  of  the  skin  characterized 
by  erythema,  vesicles,  papules  or  pustules,  attended  with  itching,  the 
production  of  more  or  less  infiltration  and  thickening  of  the  skin  conse- 
quent upon  the  serofibrinous  exudate  that  takes  place  from  the  dilated 
bloodvessels,  with  a  final  stage  of  scaling  or  crusting.  As  in  all  inflam- 
mations of  this  type,  the  tissues  return  to  their  normal  condition  on 
subsidence  of  the  disease.  Eczema  may  be  acute,  subacute,  or  chronic; 
one  form  not  necessarily  running  into  another,  but  starting  as  one  or 
the  other  as  such  at  the  outset.  More  often  in  children  we  meet  with  the 
acute  or  subacute  types,  but  by  the  continual  exacerbations  and  relapses, 
in  point  of  time,  the  disease,  in  such  cases,  may  be  said  to  be  chronic. 
Eczema  in  infancy  does  not  differ  essentially  from  eczema  in  adult 
subjects.  Certain  types  of  the  disease,  however,  may  be  more  constantly 
seen  in  infants  and  young  children  and  have  more  definite  sites  of 
election;  also  the  disease  in  them  may  be  more  rebelKous  to  treatment, 
more  irritable  and  more  liable  to  recurrence,  but  the  pathological  process 
is  the  same  in  all  and  the  term  infantile  eczema  has  no  particular  sig- 
nificance. Children  under  five  years  of  age  are  the  more  frequently 
attacked,  and  the  larger  proportion  of  cases  up  to  this  age  occur  during 

(  969  ) 


970 


DISEASES  OF  THE  SKIN 


the  first  year  of  life,  the  head  and  face  being  with  them  by  far  the 
commonest  sites  of  the  disease  (Fig.  190). 

A  greater  tenck'ncy  for  eczema  to  be  pustular  is  noted  in  infancy; 
also  its  more  ready  production,  in  those  in  whom  a  predisposition  exists, 
by  local  irritations  as  well  as  rcHexly  through  disturbances  of  the  alimen- 
tary canal.  Eczema  in  older  children  difi'ers  in  no  respect  in  its  essential 
manifestations  from  that  occurring  in  adults.  Children  of  all  ages,  but 
particularly  those  of  early  years,  ])rcscut  a  greater  tendency  to  enlarge- 
ment of  the  lymph  nodes,  but  the  frequency  and  intensity  of  the  adeno- 
pathy occurring  in  eczema  will  depend  largely  upon  the  care  with  which 
ports  of  entry  are  protected  from  the  invasion  of  pyogenic  micro- 
organisms. 


Fit;.  199 


Eczema.    (Photograph  by  Dr.  Dana  Hubbard.) 

Etiology. — The  etiology  of  eczema  is  not  preci.se.  No  child  has  ever 
been  born  with  an  eczema,  and  yet  while  eczema  cannot  be  said  to  be 
an  inherited  di.sea.se,  as  such,  the  predisposition  to  it  does  exist  and 
exists,  too,  as  a  prime  factor,  in  infantile  eczemas  as  well  as  in  the 
production  of  all  true  eczemas.  It  is  hardly  going  too  far  to  say  that 
without  a  tendency  to  the  di.sease,  inherited  or  acquired,  no  true  eczema 
can  l)e  produced.  The  arfifirinl  and  frcnimafic  eczemas,  .so-called,  are 
l)ut  simple  inflammations — flermatites,  which  on  removal  of  the  exciting 
cau.ses  and  with,  or  even  without,  simple,  appropriate  treatment  readily 
sub.side.  The.se  same  cau.se.s,  however,  acting  on  a  predispo.sed  skin 
may  produce  a  very  different  condition,  which  continues  long  after  the 
exciting  element  of  its  causation  has  been  suppres.sed,  is  more  or  less 
rebellious  to  treatment,  and  a  true  eczema  is  recognized  produced  in  a 


ECZEMA  971 

subject  with  an  underlying  eczematous  tendency  without  which  it  is  safe 
to  say  this  disease  could  not  have  been  brought  into  existence — a  der- 
matitis, yes,  but  a  true  eczema  never. 

Children  with  a  tuberculous  predisposition;  those  in  poor  surroundings 
breathing  bad  air;  ill-fed,  anemic  children  with  poor  assimilation  are 
in  a  condition  especially  favoring  germ  invasion,  and  when  exhibiting 
affections  of  the  mouth,  nose  or  throat,  with  cervical  and  submaxillary 
adenopathy,  present  the  type  known  as  lymphatic,  strumous,  or  scrof- 
ulous. They  have  a  particular  predisposition  to  eczema,  yet  it  cannot  be 
said  that  there  exists  a  tuberculous  or  scrofulous  eczema,  in  the  true 
sense  of  the  word,  any  more  than  exists  a  gouty  eczema,  which  is  merely 
an  exhibition  of  eczema  in  an  also  gouty  subject.  A  tendency  to  eczema 
is  said  to  be  one  of  the  most  frequent  manifestations  of  gout  during 
infancy.  Children  with  rheumatic  antecedents  are  also  liable  to  the 
disease.  The  commonest  exciting  cause,  the  prime  factor  almost,  in 
the  production  of  eczema  in  infants  and  young  children  lies  in  relation 
with  the  derangement  of  the  function  of  digestion,  whether  due  to  the 
food  itself — quantity  or  quality — its  administration  or  its   assimilation. 

While  no  one  of  these  factors  may  be  considered  absolute  in  pro- 
ducing eczema,  it  is  more  probably  brought  about  by  overfeeding  than 
by  any  other  cause  in  connection  with  the  food,  and  it  is  in  the  fat, 
healthy-looking,  overfed  infant,  whether  it  be  nursed  or  artificially  fed, 
that  we  meet  m.ost  frecjuently  that  familiar,  violently  itching,  florid 
form  of  eczema  of  the  face  that  has  won  for  it  the  term  "infantile." 
Poorly  nourished,  flabby  children  seldom  have  this  form  of  the  disease, 
as  it  takes  in  them  a  more  asthenic  type — dry,  scaly,  and  scattered  in 
patches  and  not  very  irritable;  the  itching  being  very  much  less  marked 
a  feature.  In  marasmic  children  eczema  rarely  discloses  itself  if  at  all. 
It  is  with  overfed  mothers'  children,  who  by  reason  of  the  easy  assimila- 
tion of  the  maternal  milk  receive  too  large  quantities  of  it  before  it 
causes  any  definite  digestive  disturbance,  and  defects  of  elimination  here 
play  the  important  part.  The  role  of  dentition  in  the  production  of 
eczema  has  been  exaggerated.  An  eczema  may  appear  long  before 
teething  begins,  and  there  is  no  valid  reason  for  forming  a  definite  type 
under  the  title  "dentition  eczema,"  for  the  process  of .  dentition  'may 
be  in  some  babies  as  painful  and  irritating  as  one  could  imagine  it 
without  producing  any  skin  manifestation  if  there  be  not  at  the  same 
time  other  underlying  conditions,  chief  of  which  is  the  individual 
predisposition. 

Teething  may  aggravate  the  eruption  by  interfering  with  the  general 
health,  but  is  never  a  sole  cause  of  eczema.  The  same  may  be  said  of 
vaccination;  it  may  light  up  for  the  first  time  an  attack  of  eczema  in 
predisposed  subjects  or  excite  exacerbations  or  recurrences  of  the 
disease  in  such  eczematous  children.  To  avoid  these  possible  accidents, 
children  in  the  French  hospitals  are  vaccinated  during  the  first  week 
or  so  of  life,  early  infancy  being  regularly  immune  to  eczema.  For 
external  causes  acting  directly  upon  the  susceptible  skin  we  have  most 
commonly  heat,  cold,  dry  winds,  too  much  washing,  or  washing  with 


972  DISEASES  OF  THE  SKIN 

hard  water  and  the  use  of  strono;,  irritating  soaps.  The  disease  may 
he  hrought  ahout  hy  l)ad  hygiene  -of  the  skin  and  hick  of  proper  care, 
especially  with  regard  to  the  diaper.  Contact  with  irritating,  altered 
discharges  from  ear,  nose,  and  mouth  causes  it.  An  eczema  of  the  upper 
lip  is  almost  invariably  due  to  a  nasal  discharge  which  must  be  corrected 
Ix'forc  hope  of  cure.  The  irritation  from  scabies,  ])ediculosis,  and  other 
parasitic  affections  of  the  skin  may  finally,  in  favorable  subjects,  result 
in  the  production  of  eczema  consequent  upon  the  scratching  induced 
by  the  intense  itching  of  these  affections,  and  finally  various  micro- 
organisms, if  not  its  source,  may  be  the  cause  of  the  continuance  of  the 
disease. 

Reflex  irritation  is  not  infrequently  an  associated  cause  of  eczema. 

Dentition,  as  a  cause,  may  be  said  to  come  under  this  head;  and  also 
irritation  from  intestinal  worms,  but  their  association  with  digestive 
disturbances  must  not  be  forgotten.  Genital  irritation  from  smegma 
confined  by  a  long  or  tight  prepuce  may  be  the  exciting  cause  of  an 
eczema  which  will  yield  to  no  treatment  until  the  foreskin  is  trained 
back  and  the  part  daily  cleansed  of  the  confined,  irritating  secretion. 
Where  this  is  not  possible  by  reason  of  a  very  long  and  tight  prepuce, 
circumcision  is  necessary. 

Varieties. — Eczema  taking  the  type  of  any  one  of  its  characteristic 
lesions  maybe  denominated  erythematous, vesicular,  papular,  or  pustular 
— the  four  primary  forms  of  the  disease.  It  is  not  to  be  understood, 
however,  except  possibly  in  the  case  of  erythematous  eczema,  that  any 
one  of  these  forms  of  the  disease  is  limited  sharply  to  the  particular 
lesion  which  titles  it;  papules  may  become  capped  with  vesicles  which, 
through  secondary  infection  by  pyogenic  micro-organisms,  become 
pustules,  the  lesions  breaking  down  and  by  extension  forming  a  weeping, 
reddened  area  denuded  of  epithelium  over  which  is  soon  formed  a  yellow 
or  yellowish-green  crust  resulting  from  the  drying  of  the  exuded  serous 
fluid  and  pus,  and  blackened  sometimes  with  blood  drawn  from  the 
raw  surface  by  the  scratching  which  the  intense  itching  induces.  Thus 
the  gamut  may  be  run  in  any  one  patch,  the  final  stage  of  all  eczemas, 
the  s(juamous,  in  turn  succeeding  before  recovery  takes  place. 

Eczema,  while  rarely  general  or  universal,  is  apt  to  be,  apart  from 
purely  external  causes  acting  locally,  more  or  less  symmetrical.  '^Fhis 
symmetry  is  fairly  constantly  seen  in  facial  eczema.    (See  Plate  XXVIII.) 

Erythematous  eczema  in  its  most  typical  form  is  met  with  most  fre- 
quently occurring  on  the  face.  Beginning  at  any  point  as  bright  or  dull 
red,  smooth  patches,  slightly  elevated  if  at  all,  with  ill-defined  borders, 
it  may  remain  in  this  patchy  state  with  trifling  subjective  symptoms,  or 
the  whole  surface  of  the  face  may  be  rapidly  involved,  accompanied  by 
a  feeling  of  tension  with  considerable  burning  or  itching  or  both,  and 
swelling;  the  eyes  at  times  being  completely  closed  owing  to  the  facility 
with  which  edema  takes  place  in  the  loose  cellular  tissues  of  the  eyelids. 
Later  there  is  but  slight  scaHness  and  the  surface  is  dry,  remaining  so 
throughout  unless  by  scratching  or  rubbing  the  skin  becomes  broken 
and  oozing  is  induced.    When  it  occurs  on  apposed  surfaces,  as  around 


PLATE   XXVIir. 


Eczema. 


ECZEMA  973 

the  genitals,  there  may  be  moisture  through  friction  and  maceration. 
The  course  of  erythematous  eczema  is  extremely  variable,  sometimes 
yielding  quickly  to  the  simplest  treatment  only  to  shortly  appear  anew 
as  bad  as  ever,  remaining  with  varying  intensity  from  day  to  day  until 
it  fairly  becomes  chronic,  thickened  and  indurated,  and  yielding  only 
to  the  most  constant  and  energetic  treatment. 

Vesicular  eczema,  while  one  of  the  most  common  expressions  of  the 
disease,  we  rarely  see  in  its  typical  form,  for  the  reason  that,  owing  to 
the  ease  with  which  the  vesicles  break,  by  the  time  it  comes  under 
observation  of  the  physician  the  tiny  superficial  vesicles  closely  aggre- 
gated on  a  reddened  base  have  already  ruptured  spontaneously  or  been 
broken  by  friction  or  scratching,  and  only  a  more  or  less  profusely 
weeping,  erythematous  surface  is  seen.  It  is  not  the  contents  of  the 
ruptured  vesicles  alone  wliich  constitute  the  discharge,  but  a  subsequent 
continuous  oozing  from  the  denuded  area  of  a  clear  plasmic  fluid  which 
stiffens  the  linen  and  stains  it  yellow.  The  discharge  drying  rapidly 
on  exposure  to  the  air,  forms  light-yellowish  granular  crusts.  The 
affected  area,  which  may  be  quite  extensive  or  confined  to  small  patches, 
is  seldom  well  defined  in  contour,  the  borders  fading  imperceptibly  into 
the  surrounding  healthy  skin.  Infiltration,  though  shght  at  times,  is 
always  present  and  can  be  appreciated  by  pinching  up  a  part  of  the 
affected  skin,  which  will  be  found  thicker  and  more  resistant  than 
normal.  The  itching  is  most  severe  and  a  child,  unless  restrained,  will 
often  by  scratching  lacerate  the  affected  part  cruelly,  rendering  it  a 
bleeding  mass  before  relief  is  thus  obtained.  This  intense  itching  and 
the  gummy-hke  exudate  staining  and  stiffening  the  linen  are  the  two 
chief  characteristics  of  this  form  of  eczema  and  can  hardly  confuse  the 
picture  with  anything  else.  This  form  of  eczema  occurring  on  the  head 
and  face  of  infants  is  known  commonly  as  milk  crust. 

Papular  eczema,  formerly  classed  in  the  hchen  group  of  skin  diseases 
under  the  title  of  lichen '  simplex,  is  a  common  and  obstinate  form. 
The  papules  are  from  the  size  of  a  small  to  a  large  pinhead,  round  or 
acuminate,  bright  red  in  color  as  they  first  appear,  later  dull  red  or 
violaceous,  and  remain  as  papules  throughout  as  a  rule.  They  may 
occur  in  small,  fairly  well-defined  groups  which,  running  together,  form 
large,  irregular,  infiltrated  patches  by  the  coalescing  of  the  individual 
papules,  or  the  papules  may  remain  discrete  and  be  scattered  irregularly 
over  sites  of  election,  the  extensor  aspect  of  the  arms  and  thighs  and  the 
trunk  being  the  favorite  places  for  the  eruption.  This  form  of  eczema 
is,  of  all  the  varieties,  the  most  intensely  itchy  and  the  summits  of  the 
papules  are  often  seen  capped  with  a  minute  blackened  crust,  a  result 
of  the  drying  up  of  the  droplet  of  blood  the  violent  scratching  brings 
to  the  torn  surface.  Papular  eczema  is  a  dry  form  of  the  disease  and 
remains  so  throughout  unless  sufficiently  irritated  by  scratching  or 
rubbing  to  induce  oozing  and  weeping.  It  is  more  often  seen  in  the 
older  children  and  adults. 

Pustular  eczema  may  supervene  upon  any  one  of  the  other  types  of 
eczema  as  the  resuU  of  secondary  infection  by  pus  cocci  or  the  lesions 


974  DISEASES  OF  THE  SKIN 

may  be  pustules  from  the  start;  itching  is  not  of  so  aggravated  a  char- 
acter as  accompanies  the  other  phases  of  the  (hsease.  Pustular  eczema 
generally  occurs  upon  the  head  and  face,  l)eing  most  often  seen  in  poorly 
nourished  children  whose  surroundings  and  hygiene  are  not  of  the  best. 
When  occurring  on  the  scalp  the  hair  becomes  matted  down  by  the 
dried  secretion  and  thick,  dirty,  closely  adherent  crusts  are  formed  from 
beneath  which  at  the  edges  the  confined  pus  makes  its  way  and,  drying, 
lends  itself  to  increase  the  crust  until  at  times  a  considerable  area  is 
involved.  In  cases  of  some  duration  there  is  often  loss  of  hair,  which  is 
not  permanent,  from  the  long  standing  inflammation  and  pus  bath  to 
which  the  j)art  has  been  subjected. 

Diagnosis. — The  diagnosis  of  eczema  in  ciiildren  presents  no  es])ecial 
difficulty,  particularly  that  form  seen  so  frecpiently  on  the  face  and  head 
of  infants  and  young  children.  These  fat,  apparently  healthy  youngsters, 
with  their  fat  cheeks  red  and  weeping  or  crusted  with  dried  exudation, 
the  inflammation  extending  in  some  cases  so  as  to  include  the  forehead, 
chin  and  ears,  with  the  nose  and  area  around  the  eyes  and  mouth  left 
free,  giving  thus  the  appearance  of  a  mask  with  the  centre  cut  out, 
present  a  picture  so  typical  that  it  could  hardly  be  confounded  with 
anv  other  condition.  Eczema  occurring  around  the  buttocks  and 
genital  region  of  infants  is  generally  fairly  confined  to  the  area  of  the 
diaper;  syphilis  of  this  region  extends  farther  along  the  limbs  down  to 
the  feet,  the  soles  being  often  involved ;  besides  the  characteristic  snuffles 
and  other  evidences  of  syphilis  would  generally  be  present  to  help  out 
the  diagnosis,  as  in  any  other  form  of  eczema  for  which  syphilis  might 
be  mistaken.  Papvdar  eczema  in  its  intense  itchiness  and  character  of 
lesions  may  be  taken  for  scabies,  but  the  situations  and  distribution  of 
the  eruption  of  the  latter  would  help  to  clear  up  the  difficulty  together 
with  its  manifestation  in  other  members  of  the  family.  In  infants  who 
are  nursing  from  a  scabies  infected  mother,  aside  from  the  typical  place's, 
the  face  and  scalp,  from  close  contact  with  the  breasts,  may  present  the 
characteristic  burrows  and  scattered  eruption  of  scabies,  and  likewise 
the  feet  and  buttocks  from  the  infected  hands  of  the  mother  may  be 
similarly  involved.  In  older  children  these  evidences  of  scabies  are 
more  manifest  in  the  situations  commonly  affected  by  the  itch  mite;  the 
flexures  of  the  wrists,  skin  between  the  fingers,  folds  at  the  margins, 
anterior  surface  of  the  body,  the  inner  surface  of  the  thighs,  and  the 
sheath  of  the  penis.  In  all  these  places,  if  carefully  looked  for,  the 
characteristic  burrows  may  be  discovered  from  which  with  care  an 
acarus  can  be  picked.  While  in  all  these  situations  paj)ular  eczema,  too, 
may  occur,  its  lesions  are  more  often  grouj)ed  and  patchy,  not  so  irreg- 
ularly scattered  as  in  scabies.  Papular  eczema  and  a  papular  form  of 
urticaria  may  be  mistaken  for  each  other,  but  the  presence  of  wheals  in 
the  latter  would  clear  up  the  difficulty.  In  prurigo,  the  history,  its  more 
general  distribution  and  chronicity,  together  with  the  characteristic 
inguinal  adenopathy,  would  differentiate  it  from  papular  eczema. 
Pustular  eczema  of  the  scalp  closely  resembles  impetigo  of  this  region, 
but  the  latter,  when  set  up  by  pediculosis  capitis,  its  most  common  cause, 


ECZEMA 


975 


IS  almost  exclusively  confined  to  the  occipital  region  and  nape  of  the  ne(;k; 
eczema  of  the  scalp  is  not  so  Kmited;  besides,  nits  would  be  discovered 
if  not  the  pedicuH  themselves,  and,  furthermore,  treatment  would  be 
quickly  decisive.  The  characteristic  isolated  lesions  of  contagious 
impetigo,  looking  as  if  stuck  on  the  sound  skin,  some  of  which  alwavs  occur 
outside  of  a  larger  main  patch,  would  determine  the  diagnosis  between 
this  disease  when  on  the  face  and  pustular  eczema.  The  microscope 
would  clear  up  any  particular  difficulty  should  it  occur  between  the 
diagnosis  of  ringworm  of  the  scalp  or  body  and  eczema. 

Prognosis.— Eczema  if  left  to  itself  untreated  runs  on,  as  a  rule, 
indefinitely,  showing  but  little  tendency  to  spontaneous  recovery, 
especially  during  the  early  years  of  fife,  when  at  times,  even  under  the 
most  painstaking  care,  it  persists  in  a  disheartening  way  to  those  con- 
cerned. Ultimate  cure,  though,  can  be  brought  about  by  judicious  local 
treatment  combined  with  attention  to  the  diet  and  correction  of  chronic 
indigestion  and  constipation  when  these  exist.  Every  effort  should  be 
made  to  seek  out  and  eliminate  any  and  all  underlnng  causes.  Other- 
wise any  more  than  temporary  rehef  can  hardly  be  hoped  for  by  local 
measures  and  the  constant  recurrence  and  lighting  up  through  weeks 
and  months  of  what  seemed  at  times  almost  a  conquered  disease  will 
tax  the  skill  of  the  physician  and  patience  of  the  mother  to  the  utmost, 
to  say  nothing  of  the  torment  by  itching  to  the  bearer  of  the  disease. 
Oddly  enough  the  general  condition  and  spirits  of  many  infants  with  a 
persistent  eczema  of  the  face  seems  but  little  affected;  they  go  on  gaining 
weight  and  appear  in  nowise  the  worse  for  the  violent  paroxysms  of 
itching  during  restless  nights,  while  the  mother  or  nurse  is  worn  out  by 
the  watchful  attention  the  little  sufferer  recjuires. 

Treatment. — That  an  eczema  should  be  treated  there  ought  to  be  no 
cjuestion  and,  indeed,  the  old  idea  of  its  being  a  vent  for  poisonous 
material  in  the  blood  and  its  suppression  causing  other  worse  (but 
unknovrn)  diseases  to  spring  into  existence  is  entertained  but  little 
to-day  and  only  by  those  of  but  the  most  meagre  intelligence  upon  the 
subject.  Always  terminate  an  eczema  as  speedily  as  possible,  especially 
when  on  the  face,  if  only  from  a  cosmetic  point  of  view;  doing  so  will 
never  prove  dangerous  and  the  other  organs  of  the  body  will  go  un- 
harmed. If  it  "strikes  in"  and  Avill  only  stay  in,  so  much  the  better  for 
all  concerned.  In  approaching  an  eczema,  whether  in  children  or  adults, 
with  any  hope  of  successfully  treating  it,  the  aim  should  be  to  determine 
the  exciting  cause  and  remove  it;  then  further  seek  to  put  the  body  in  such 
condition  that  the  underhnng  tendency  may  be  less  responsive  to  the 
exciting  stimuli,  external  or  internal,  which  produce  the  eczema.  Until 
tliis  be  fairly  accomplished  hopes  of  a  permanent  cure  are  futile,  for 
local  treatment  alone  will  afford  but  temporary  benefit  at  best  on  all 
but  a  ver}^  small  majority  of  cases.  There  can  be  but  little  difficulty 
in  ascertaining  what  may  be  the  external  causes,  for  by  observation  and 
by  question  of  those  in  charge  these  may  be  readily  discovered,  and 
while  the  internal  causes  are  generally  due  to  some  disturbance  of  the 
digestive  tract,  or  related  to  a  functional  disturbance  of  the  fiver  or  kidney, 


976  DISEASES  OF  THE  SKIN 

it  is  not  always  at  first  that  one  can  put  his  fin(ii;t>r  on  just  the  exact 
conthtion  responsible.  Investigation  of  the  food  in  every  particular 
relatini^  to  it  is  of  the  first  importance,  for  it  is  in  the  errors  of  diet  that 
the  most  fruitful  sources  of  eczema  in  children  will  be  found.  Exami- 
nation of  the  mother's  milk  at  the  outset,  if  the  child  be  nursing,  will 
save  time  and  obviate  a  speculative  groping  in  the  dark  as  to  whether 
excess  of  the  proteid  or  the  fats  be  causing  the  trouble.  Regulation  of 
this  should  be  brought  about  by  attention  to  the  mother's  diet,  seconded 
by  having  her  take  systematic  out-door  exercise,  which  alone  at  times 
will  so  alter  for  the  better  the  quality  of  the  milk  that  a  marked  improve- 
ment will  often  be  noted  in  an  hitherto  obstinate  eczema  of  the  face 
of  a  nursing  infant.  In  older  children,  uj)  to  three  years  of  age,  espe- 
cially those  allowed  to  come  to  the  table,  uverfccdiiig  is  the  common 
error  together  with  injudicious  food.  In  clinical  practice,  upon  question- 
ing mothers  as  to  what  the  child  eats,  a  common  answer  is:  "Any  and 
everything,  just  what  there  is,"  and,  one  might  add,  and  at  all  times. 
If  such  children  be  limited  to  milk  alone  for  a  week  or  more  a  marked 
change  for  the  better  will  often  be  noted  in  an  eczema  that  formerly, 
under  the  same  treatment  locally,  had  proved  most  resistant.  All 
children  with  an  eczema  should  be  given  plentifully  of  water  between 
meals,  it  facilitates  assimilation  and  is  better  than  drugs  for  constipation. 
It  is  useless  to  lay  down  precise  rules  for  feeding,  what  may  agree  with 
one  will  not  agree  with  another,  and  the  diet  that  suits  best  can  only  be 
found  out  by  experimenting  in  each  individual  case.  In  general  starchy 
food,  especially  cereals  and  potatoes,  should  be  eliminated  and  some- 
times even  meats  during  the  active  stage  of  an  eczema.  The  regulation 
of  the  bowels  is  of  the  greatest  importance  when  constipation  exists, 
getting  rid  of  this  stumbling  block  is  more  than  half  the  battle  in  many 
cases.  Calomel  in  doses  of  0.0065  gm.  (yif  gr.),  three  times  daily  for 
fat  babies,  is  of  the  greatest  service,  and  in  older  children,  used  in  purg- 
ative doses,  two  or  three  times  in  ten  days,  will  go  far  toward  relieving 
the  congestion  of  the  face.  The  bowels  should  not  only  be  opened  but 
kept  open  daily,  and  if  necessary  by  drugs,  the  milder  laxatives,  such  as 
the  mixture  of  rhubarb  and  soda  (U.  S.  P.)  alone  or  in  combination,  and 
cascara  may  be  used,  always  giving  plentifully  of  water  throughout  the 
day  between  meals.  Other  drugs,  such  as  arsenic  and  antimony,  have 
but  a  traditional  value  as  specifics.  Whatever  may  be  the  temptation  to 
use  arsenic,  at  least  let  it  not  be  yielded  to  during  the  acute  stage  of 
an  eczema.  Cod-liver  oil  in  poorly  nourished  children  is  often  of  use 
and  the  syrup  of  the  iodide  of  iron,  wine  of  iron,  and  bitter  tonics  are  of 
value  in  anemia. 

In  general  management  the  first  importance  is  the  constant  protection 
of  the  skin  from  contact  with  the  air;  a  dressing  left  off  and  the  skin 
exposed  for  several  hours  will  often  undo  days  of  treatment.  A  child 
with  eczema  of  the  face  properly  protected  may  be  taken  out  in  any 
sort  of  weather  to  which  it  ordinarily  is  exposed  and  be  the  better  for 
it.  In  removing  crusts,  poultices  of  starch  jelly  applied  when  cold  and 
renewed  every  few  hours  will  be  found  very  efficacious  and  soothing, 


ECZEMA 


977 


or  strips  of  flannel  soaked  in  sweet  oil  left  on  overnight,  covered  with 
rubber  tissue,  will  loosen  up  the  crusts  so  that  they  may  be  readily 
removed  the  next  morning,  not  by  washing  with  soap  and  water,  however, 
but  gently  cleared  away  with  a  soft  cloth  dipped  in  oil.  Water,  much 
less  soap,  should  never  be  allowed  to  touch  an  acute  exuding  eczema. 
In  removing  particles  of  former  applications  which  adhere  to  the  surface, 
as  when  stiff  pastes  are  used,  oil  answers  every  purpose,  and  with  care 
every  trace  can  be  removed  without  undue  injury.  That  an  absolute 
exclusion  of  water  from  all  eczematous  surfaces  is  essential  is  a  mistaken 
idea;  in  erythematous  patches  where  the  surface  is  dry  and  in  papular 
eczema  there  is  no  reason  for  doing  away  with  the  benefits  of  the  daily 
bath.  Soap  and  water  energetically  applied  with  hard  scrubbing  even 
enters  into  the  treatment  of  some  forms  of  eczema,  and  in  cases  where 
extensive  surfaces  of  the  body  and  limbs  are  involved,  a  rather  prolonged 
immersion  in  water  kept  at  a  comfortable  temperature  and  softened 
with  bran  or  starch  will  be  found  extremely  soothing  and  grateful  to  the 
irritated  skin,  often  securing  immunity  from  scratching  for  hours  at  a 
time  and  if  used  at  bedtime  affording  a  quiet  night.  Where  proper 
attention  can  be  had  there  should  be  no  necessity  for  tying  children's 
hands  to  prevent  scratching;  doing  this  only  irritates  them  the  more  in 
their  attempts  to  get  their  hands  free  and  makes  them  more  restless. 
The  physician  should  be  able  to  cope  with  this  and  it  is  his  duty  to 
supply  means  of  relief  and  the  attendants  to  employ  them  at  any  and 
all  times  required,  for  scratching  and  tearing  the  skin  must  be  obviated 
at  any  cost.  Where  constant  attention  is  not  feasible  the  most  humane 
method  is  to  use  cardboard  splints  at  the  elbows  so  that  the  hands, 
though  free,  cannot  reach  the  face.  Anodynes  for  the  relief  of  itching 
should  not  be  even  thought  of. 

Strict  attention  to  cleanliness  should  be  enforced,  the  diaper  should 
be  removed  as  soon  as  soiled  and  replaced  by  a  clean  one.  Stearate 
of  zinc  powder,  medicated  or  not,  should  be  dusted  on;  it  affords  the 
best  protection  to  the  skin,  it  is  more  adherent  than  most  powders, 
and,  being  non-absorbent,  the  urine  is  prevented  from  coming  in  con- 
tact with  the  parts  to  any  great  extent. 

Notwithstanding  the  importance  of  internal  treatment,  some  form  of 
local  treatment,  if  only  as  an  adjunct  to  the  former,  is  nearly  always 
necessary,  and  some  forms  of  eczema  indeed  are  cured  by  local  measures 
alone.  At  the  outset  it  will  be  well  to  bear  in  mind  two  general  principles 
as  set  forth  by  Van  Harlingen  with  regard  to  the  local  treatment  of 
eczema.  These  are,  first,  that  in  the  acute  form  the  treatment  can 
hardly  be  too  soothing;  secondly,  that  in  the  chronic  form  the  treatment 
(within  limits,  of  course)  can  hardly  be  too  stimulating.  To  avoid  to 
some  extent  the  confused  notions  as  to  local  applications  that  result 
more  often  than  not  from  just  giving  a  list  of  prescriptions  with  general 
suggestions  as  to  their  use,  I  think  it  simpler  to  consider  the  various 
forms  of  eczema,  together  with  location,  and  taking  up  a  type,  as  far  as 
possible,  give  directions  that  suit  it  which  may  be  followed  out  more 
or  less  in  similar  cases, 
63 


078  DISEASES  OF  THE  SKIN 

In  the  presence  of  the  familiar  picture  of  an  acute  vesicular  eczema 
on  the  face  of  an  infant  with  the  infiamerl  skin  oozing  and  crusteci,  the 
first  thing  to  be  done  is  to  remove  the  adherent  crusts  so  that  whatever 
is  to  be  used  later  may  come  in  contact  with  the  diseased  surface.  This 
is  best  done  by  applying  a  cold  starch-jelly  poultice  as  before  stated, 
and  then  by  apj)lying  pledgets  of  lint  soaked  in  sweet  oil.  Another 
method  is  to  lay  on  the  crusted  surface  strips  of  flannel  soaked  in  sweet 
oil,  covering  these  with  rubber  tissue,  binding  them  well  on  and  allowing 
them  to  remain  in  place  overnight;  the  following  morning  the  surface  can 
be  readily  freed  from  the  crusts  with  sweet  oil  and  made  ready  for  the  next 
step.  Soap  and  water  .should  not  be  used  to  remove  the  crusts.  So  that 
the  infiamed  skin  be  exposed  to  the  air  for  as  short  a  time  as  possible  after 
cleansing,  a  mask  made  of  absorbent  gauze  should  have  been  previously 
prepared  spread  and  ready  for  immediate  use  with  the  following  paste : 

]pl— Acid,  salicylic 0.10  gm.  (gr.  xv). 

Amyli, 

Zinc.  oxid. da  8.00  gm.  (5ij). 

Ung.  petrol q.  s.  ad  SOOOgm.  fsj).— M. 

This  protective  mask  is  to  be  well  bound  on,  openings  having  been  made 
for  the  nose,  eyes,  and  mouth.  Several  layers  of  absorbent  gauze  mu.st  be 
used  in  making  the  mask  and  the  paste  spread  on  evenly  to  the  thickness 
of  3.2  mm.  (fully  \  inch)  thick.  This  dressing  should  be  kept  on  day 
and  night  and  renewed  twice  in  the  twenty-four  hours.  After  each 
removal  of  the  mask  and  before  making  a  fresh  dressing  the  face  is  to 
be  freed  of  adherent  particles  of  the  former  dressing  by  the  use  of 
sweet  oil.  In  this  paste  the  amount  of  salicylic  acid  may  be  diminished 
or  omitted  entirely  according  to  the  irritability  of  the  skin;  in  most  cases 
it  can  be  used  freely  as  above.  The  practical  use  of  this  paste  is  as 
follows:  The  vaselin  is  largely  taken  up  by  the  absorbent  gauze, 
leaving  a  more  or  less  porous  mass  which  absorbs  the  exudation  as  it 
comes  from  the  weeping  surface;  hence  simply  smearing  the  paste  thinly 
on  or  using  it  without  a  covering  of  gauze  defeats  the  purpose  for  which 
Lassar  devised  it. 

The  dressings  with  this  paste  may  be  found  all  that  is  necessary  to 
a  cure;  if  not,  and  to  complete  it  more  stimulating  treatment  be  recjuired, 
one  proceeds  to  the  use  of  tar.  It  is  always  a  delicate  cjuestion  to  decide 
just  when  tar  is  to  be  u.sed,  but,  as  a  rule,  it  should  only  be  employed 
after  exudation  has  entirely  ceased  and  sound  skin  has  formed.  To 
get  the  proper  benefit  from  tar  com|M)un<ls  they  must  be  rubbed  in, 
not  merely  laycfl  on.  The  following  is  a  good  compound  in  which  the 
amount  of  tar  may  be  varied  to  suit  the  case,  trying  smaller  amounts 
at  first  and  on  limited  areas  to  get  the  eflect  desired: 

^ — Oleo  cadini 4.0  gm.       (5j). 

Ung.  zinc,  oxid q.  s.  ad    30.0  gm.        (Sj). 

This  is  to  be  gently  worked  in  and  appropriate  dressings  made. 


ECZEMA  979 

Acute  eczema  of  the  above  type  occurring  on  any  part  of  the  body 
may  be  treated  on  the  same  hnes. 

In  cases  where  there  is  no  weeping  or  but  very  shght  oozing  the 
following  lotion  may  be  used  at  the  start: 

^fZinc.  oxid 40  parts. 

IPulv.  cretae. 20      " 

-  ( Lot.  plumbi, 
toi.  lini aa    20  parts. 

The  ingredients  of  a  and  b  are  to  be  mixed  separately  and  then  the 
two  together. 

This  lotion  will  be  found  most  efficacious  and  as  it  dries  quickly  and 
is  very  adherent  it  is  not  readily  rubbed  off  and  no  outside  covering  is 
necessary — a  great  advantage.     It  is  to  be  removed  with  oil. 

In  pustular  eczema  of  the  scalp  the  head  is  to  be  freely  anointed  with 

51 — Acid,  salicylic 1.65  gm.       (gr.  xxv). 

01.  amygdal.  dulcis    . 30.00  gm.        (Sj). 

and  bound  up  in  flannel  cloths  covered  with  gutta-percha  tissue  or  a 
rubber  cap  until  all  crusts  and  scabs  can  be  removed,  continuing  the 
salicylated  oil  for  a  few  days  until  the  hyperemia  and  pustulation  are 
abated;  then  the  oil  of  cade  up  to  4  c.c.  (1  dr.)  to  30  c.c.  (1  oz.)  of  sweet 
oil  or  vaselin  can  be  apphed. 

White  precipitate  ointment  from  1.3  gm.  (20  gr.)  up  to  4  c.c. 
(1  dr.)  to  30  gm.  (1  ounce)  of  vaseUn  will  be  found  useful,  but  this 
ointment  must  be  carefully  made  to  get  full  benefit.  Pastes  and  stiff 
ointments  are  to  be  avoided  on  the  scalp  unless  the  hair  be  closely 
clipped. 

In  papular  eczema  ointments  are  generally  to  be  avoided  and  lotions 
used.    One  that  has  proven  the  most  generally  useful  is  the  following : 


Jfe — Acid,  carbolic. 
Zinc.  oxid. 
Glycerin.     . 
Aquae  rosae  . 


2.92  gm.  (gr.  xlv). 

5.85  gm.  (3iss). 

9  25  c.c.  (fSiiss). 

q.  s.  ad    120.00  c.c.  (fSiv). 


The  amount  of  carboHc  acid  in  this  may  be  diminished  or  increased. 
Lime-water  may  be  used  in  place  of  rose-water.  This  lotion  will  be  found 
most  efficacious  in  allaying  itching  in  general;  where  burning  is  the 
more  pronounced  element  the  following  will  be  found  better: 

Jfc — Calamin.  prep., 

Zinc,  oxid aa  4.0  gm.  (5j). 

Glycerin 8-0  o.c.  (f5ij). 

Aquffi  rosEB q.  s.  ad  120.0  c.c.  (fSiv). 

This  will  be  useful  also  for  the  burning  and  smarting  of  beginning 
erythematous  eczema  and  wherever  a  soothing  application  may  be 
needed. 

For  patches  of  chronic  eczema  where  there  is  thickening  and  indura- 
tion of  the  skin  the  use  of  tar  can  be  instituted  at  once,  beginning  with 
varying  strengths  of  tar  ointments  up  to  the  pure  oil  of  cade.     More 


980  DISEASES  OF  THE  SKIN 

satisfacton'  results  ran  be  obtained  by  the  following  process:  Remove 
all  accumulation  of  scales  from  the  patch,  then  friction  in  with  a  stiff 
brush  for  ten  or  twenty  minutes  the  following  ointment: 

51 — Oleocadini 4  c.c.        (3j). 

Ung.  petrol q.  s.  ad    30  c.c.       (3j).— M. 

With  a  soft  cloth  the  excess  of  ointment  is  to  be  removed  and  the 
now  somewhat  irritated  patch  painted  with  this  .solution: 

Ichthyol 1  to  2  parts. 

Water 3  "  2     " 

This  mixture  dries  in  a  few  minutes  and  forms  a  thoroughly  protective 
varnish,  obviating  the  nece.s.sity  for  further  dressings.  If  complete 
drying  of  the  varnish  is  slow,  dust  over  with  lycopodium  or  starch 
powder.  The  ichthyol  varnish  is  to  be  removed  before  the  next  rubbing 
with  the  tar  ointment;  this  can  be  readily  done  with  a  damp  cloth. 
Repeat  the  above  procedure  twice  daily,  morning  and  night.  Immediate 
results  further  than  allaying  the  itciiing  can  hardly  be  expected  in 
treating  chronic  eczemas,  but  perseverance  with  the  above  method, 
increasing  the  amount  of  tar  as  may  be  necessary,  will  finally  bring 
success. 

ECTHYMA. 

Ecthyma  is  a  definite  inflammatory  disease  of  the  .skin,  the  e.s.sential 
and  con.stant  lesion  of  which  is  a  pu.stule  .situated  on  an  indurated  base, 
tending  to  enlarge  peripherally  by  subepidermic  inva.sion  of  the  imme- 
diate ti.ssue,  surrounded  by  an  exten.sive  bright-red  areola,  and  healing 
under  a  black  or  yellow  cru.st,  with  the  production  of  more  or  less  pig- 
mentation and  scarring.  The  affection  is  contagious,  though  not  so 
greatly  as  impetigo,  is  inoculable  and  autoinoculable,  and  is  due  to  the 
invasion  of  the  epidermis,  more  or  less  deeply,  by  a  pyogenic  organism, 
the  exact  nature  of  which  has  not  as  yet  been  definitely  determined. 
The  implantation  of  the  infective  agent  is  favored  by  conditions  which 
tend  to  lower  the  general  vitality — pf)or  surroundings,  ill  nourishment, 
gastrointestinal  troubles,  etc.,  and  is  more  often  seen  in  children  who 
have  the  so-called  strumous  diathesis.  Body  parasites  constitute  a 
fref|uent  determining  cause  for  the  appearance  of  ecthyma  lesions. 

Symptomatology. — While  occurring,  as  a  rule,  in  the  poorer,  ill-kept 
classes,  and  in  children  of  the  better  cla.ss  after  depre.s.sing  general 
diseases,  an  accidental  lesion  may  make  its  appearance  on  any  one. 
Constitutional  .symptoms  directly  due  to  the  eruption  itself  are  rare. 
The  subjective  .symptoms  are  at  first  itching  and  burning,  though  not 
very  pronounced;  later,  in  the  fully  developed  lesion  a  feeling  of  tension 
and  pain  will  be  felt.  I>ymphangitis  and  adenitis  are  sometimes  compli- 
cations. The  le.sions  vary  in  size  from  a  pea  to  a  dime,  sometimes 
larger,  before  crusting  begins;  are  generally  few  in  number,  often  but 
one  or  two,  seldom  more  than  a  dozen;  always  occur  discretely,  and 


ECTHYMA  981 

are  confined  chiefly  to  the  extremities,  particularly  the  lower.  The 
face  and  scalp  are  seldom  attacked  and  the  mucous  membranes  never. 
The  course  of  the  disease  is  acute,  running  from  ten  days  to  two  weeks 
up  to  the  formation  of  the  crusts,  after  this  the  length  of  the  process 
of  repair  depends  upon  the  extent  of  the  ulceration  that  has  taken  place 
beneath  the  crusts.  By  autoinoculation  and  the  continuance  of  the 
cause  the  appearance  of  new  lesions  may  persist  almost  indefinitely. 
Inoculation  with  the  pus  from  an  ecthymatiform  pustule  always  produces 
a  similar  pustule,  and  I  have  produced,  experimentally  on  myself,  pus- 
tules through  the  fifth  generation,  the  original  pus  having  been  taken 
from  a  fresh  lesion  on  a  child.  Each  succeeding  pustule  was  smaller 
than  its  predecessor,  and  beyond  the  fifth  one  reinoculation  proved 
abortive,  the  power  to  reproduce  seeming  to  have  died  out,  or  possibly 
the  soil  became  unsuitable  to  the  growth  of  the  specific  germ.  Cultures 
resulted  in  the  demonstration  of  but  the  ordinary  staphylococci  and 
streptococci,  which,  however,  when  inoculated  give  various  results. 

The  lesion  of  ecthyma  has  a  very  regular  and  definite  evolution.  In 
a  few  hours  after  inoculation  a  small,  red,  itchy  point  appears,  which 
increases  in  size  up  to  three-eighths  of  an  inch  in  diameter  by  the  second 
day,  when  a  minute  pustule  appears  in  its  centre ;  by  the  fourth  or  fifth 
day  the  full  development  of  the  ecthymatiform  lesion  is  established  in 
the  form  of  a  yellow  pustule  the  size  of  a  small  split  pea,  seated  on  an 
indurated  base  circled  by  a  whitish  ring  of  loosened  epidermis  a  sixteenth 
of  an  inch  in  width,  marking  the  advancing  area  of  pustulation,  outside 
of  which  again  is  a  bright-red  areola  a  quarter  of  an  inch  or  more  in 
width.  Throughout  the  succeeding  days  all  these  elements  of  the 
lesion  advance — the  two  encircling  bands  keeping  about  the  same 
width,  the  pustule  increasing  in  area  up  to  the  ninth  or  eleventh  day. 
Drying  then  begins  at  the  centre  of  the  pustule,  which  flattens  down 
into  a  black  or  brownish  crust,  still  surrounded  by  the  whitish  ring  of 
pus-loosened  epidermis  and  the  outside  red  areola.  The  process  may 
stop  at  this  point  and  healing  take  place  in  from  fifteen  to  twenty  days, 
leaving  a  superficial  cicatrix,  with  moreor  less  brownish-red  pigmentation 
which  slowly  disappears.  Sometimes  the  process  extends,  the  advancing 
area  of  pustulation  being  marked  by  the  whitish  ring  of  loosened  epi- 
dermis, the  crust  becomes  larger,  the  ulceration  more  extensive,  and  a 
lesion  of  considerable  dimension  may  be  attained.  There  is  a  rare  and 
more  destructive  variety  of  ecthyma  entirely  peculiar  to  very  young 
children  and  infants — the  ecthyma  teoehrant,  ecthyma  ulcereux  of  French 
authors,  and  allied  to,  if  not  identical  with,  the  gangrenous  lesions 
described  as  following  varicella,  measles,  etc.  (Duhring),  under  various 
titles,  viz.,  infantile  gangrenous  dermatitis,  ecthyma  gangrenosa,  vari- 
cella gangrenosa,  etc.  It  is  characterized  by  the  formation  of  papulo- 
pustules or  quite  large  pemphigoid  bullae  of  brief  duration,  under  wliich 
develop  circular  or  oval,  sharply  defined,  punched-out  ulcers,  surrounded 
by  a  slight  erythematous  areola;  the  ulceration  spreads  rapidly,  super- 
ficially, and  in  depth,  penetrating  at  times  through  the  derma  to  the 
subcutaneous  fat;  the  edges  of  the  ulcer  are  indurated  and  considerably 


982  DISEASES  OF  THE  SKIN 

raised,  giving  a  crater-like  form  to  the  ulcer  and  a  depth  to  it  more 
apparent  than  real.  This  is  well  portrayed  in  Plate  XXIX.  The  infection 
spread  by  antoinoculation,  may  give  rise  to  numerous  closely  aggregated 
lesions,  which,  coalescing,  form  large,  polycyclic  patches.  The  lesions  of 
this  severer  form  of  ecthyma,  though  found  on  the  buttocks,  thighs, 
inguinal  region,  back,  and  abdomen,  are  chiefly  situated  on  the  upper 
and  posterior  j)arts  of  the  thighs  and  buttocks  where  the  diaj)er  comes 
in  more  intimate  contact  with  the  skin,  for  it  is  chiefly  through  main- 
tenance of  filth  in  this  connection  that  these  parts  are  so  abundantly 
invaded.  Accidental  lesions  through  secondary  infection  may  be  found 
on  any  part  of  the  body,  even  the  scalp,  and  not  infrecjuently  the  nuicous 
membrane  of  the  mouth  has  been  involved.  This  form  of  ecthyma, 
while  grave,  is  not  necessarily  fatal,  and  the  lesions',  though  often 
remaining  stationary  for  long  periods,  heal  slowly,  leaving  indelible  scars. 

Diagnosis. — Ecthyma  may  chiefly  be  distinguished  from  impetigo, 
with  which  it  is  most  often  confounded,  by  its  more  distinctly  ])ustular 
nature — ecthyma  is  always  pustular.  It  further  differs  by  the  greater 
depth  of  its  lesions,  the  inflammatory  areola,  and  whitish  line  of  under- 
mined epidermis  siuTounding  the  pustule  or  crust.  Impetigo  nearly 
always  occurs  on  the  face,  with  characteristic  stuck-on,  yellow,  honey-like 
crusts,  ecthyma  on  the  extremities  with  flat,  blackish-brown  crusts 
surrounded  by  an  extensive  inflammatory  areola. 

Furuncle  differs  from  ecthyma  in  its  more  extended  and  vivid  redness, 
greater  tumefaction  of  the  tissues,  its  central  core,  and  greater  pain. 

From  pustular  eczema  ecthyma  may  be  distinguished  by  the  scarcity 
of  its  lesions;  their  occurring,  as  a  rule,  discretely;  the  size  of  its  pustules; 
their  inflammatory,  firm  base  and  external  areola. 

Treatment. — Ecthyma,  as  a  rule,  is  easily  controlled  by  proper  treat- 
ment. The  first  efforts  should  be  directed  toward  putting  the  patient 
in  as  hygienic  surroundings  as  possible,  with  daily  attention  to  cleanliness, 
bathing,  and  fresh  air;  the  diet  should  be  looked  into  and  made  as  fully 
nutritious  as  possible.  Tonics,  as  in  combinations  of  iron,  arsenic, 
quinine,  and  strychnine;  the  syrup  of  the  iodide  of  iron  and  cod-liver  oil 
may  often  be  used  with  benefit,  and  in  some  cases  are  indispensable. 
Local  treatment  is  of  great  importance.  If  parasites  be  acting  as 
exciting  causes,  these  should  first  be  done  away  with.  After  having 
removed  the  crusts  from  the  lesions  by  antiseptic  poultices,  soaking  in 
sweet  oil,  or  by  prolonged  alkaline  baths  or  water  dressings  of  carbolic 
or  bichloride  of  mercury,  all  source  of  reinoculation  may  be  removed 
by  thoroughly  bathing  the  excoriated  or  ulcerated  surfaces  with  1:60 
carbolic  acid  solution  or  1 :  1000  bichloride  of  mercury  solution  or 
stronger,  followed  by  some  constant  occlusive  dressing,  the  object  of 
this  being  as  much  a  cure  as  a  preventive  against  possible  reinfection 
by  scratching.  For  this  purpose  a  white  precipitate  ointment  spread 
on  cheese-cloth,  and  exactly  fitting  the  lesion  and  bound  on,  may  best  be 
used;  4  gm.  (1  dr.)  to  30  gm.  (1  oz.)  of  the  ammoniated  mercury  in 
vaselin  is  none  too  strong,  or  the  ordinary  mercury  plaster  may  be 
bound  on.     Pustules  should  be  opened  and  treated  in  the  same  way; 


PLATE  XXIX. 


■*    *-*. 


U^ 


Ecthyma. 


URTICARIA 


983 


dressings  should  be  made  twice  daily— the  parts  being  thoroughly 
cleansed  before  reapplying  the  ointment.  Various  other  drugs,  such  as 
calomel,  aristol,  iodoform,  naphthol,  etc.,  may  be  used  in  ointment  or 
powder  form,  but  the  white  precipitate  will  be  generally  found  all 
sufficient.  If  healing  be  slow  and  the  sores  sluggish  they  may  be  touched 
with  pure  carbolic  acid,  solutions  of  silver  nitrate,  or  the  stronger  silver 
point  itself.  In  the  deeper  ulcerative  forms  of  ecthyma,  where  there  is 
a  gangrenous  tendency,  astringent  lotions  should  be  used,  later  coming 
to  the  mercurial  ointment.  One  of  the  best  lotions  for  this  purpose  is 
the  following: 

P— Alum 5  parts. 

Plumbi  acetat. 25      " 

Aquae 500      " 

Ecthyma,  as  a  rule,  terminates  most  favorably,  except  for  the  scarring, 
and  it  is  only  in  the  most  neglected  cases,  following  depressing  general 
conditions,  where  deep  and  extensive  ulceration  has  taken  place,  that 
the  disease  is  at  all  grave,  and  even  here  not  necessarily  fatal  if  proper 
change  of  conditions  be  provided  and  treatment  instituted  and  carried 
out. 

URTICARIA. 

Urticaria  is  an  angioneurotic  disturbance,  manifesting  itself  ordinarily 
by  the  rapid  production  in  the  skin  of  swellings  or  "wheals,"  accom- 
panied by  itching,  burning,  and  tingling. 

The  affection  announces  itself  by  an  intense  itching  and  the  appear- 
ance of  the  characteristic  wheals,  constituting  the  famiUar  "Hives"  or 
"Nettle  Rash."  The  fever  and  other  disturbances  which  may  accompany 
an  acute  onset  of  urticaria  have  more  to  do  with  the  underlying  cause 
of  the  attack  than  with  the  eruption  itself,  ordinarily  only  the  distressing 
itching  and  burning  mark  the  variation  from  the  normal  condition. 

The  wheals  appearing  in  successive  crops  may  be  very  generally 
distributed  over  the  body  or  be  confined  to  certain  portions — the  face, 
shoulders,  neck,  arms,  thighs,  or  abdomen — these  being  the  more  usual 
seats  for  the  development  of  the  lesions.  They  appear,  in  the  common 
type  of  urticaria,  as  fairly  prominent  elevations  of  the  skin,  with  sloping, 
irregular  borders,  velvety  to  the  touch,  varying  in  size  from  19.05  mm. 
(f  inch)  or  less  to  3.175  cm.  (If  inches).  The  color  of  the  wheal  is 
at  first  pink  or  red,  may  remain  so,  or,  later,  change  to  white,  depending 
upon  the  intensity  of  the  serous  infiltration  in  the  derma.  Generally 
discrete,  the  wheals  may  become  confluent  and  form  extensive  patches. 
The  transitory  nature  of  the  urticarial  lesions  is  their  essential  char- 
acteristic; they  appear  and  disappear  with  almost  equal  rapidity, 
leaving  one  place  to  suddenly  spring  up  in  another,  effacing  themselves 
without  the  least  trace  of  their  existence,  except  at  times  a  slight  pigmen- 
tation. The  duration  of  an  individual  lesion  varies  from  a  minute  or 
two  to  several  hours.  The  intense  itching,  which  is  a  pretty  constant 
accompaniment  of  an  urticarial  outbreak,  is  increased  on  exposure  of 


984  DISEASES  OF  THE  SKIN 

the  surface  to  the  air,  and  is  generally  most  marked  at  bedtime,  thus 
causing  in  some  cases  distressing  nights  of  restlessness.  Beyond  the 
loss  of  sleep,  wliich  may  become  serious  in  prolonged  cases  and  affect 
the  health  of  the  child,  the  general  condition  remains  undisturbed. 

Papular  or  Papulovesicular  Urticaria. — This  is  a  variant  from  the 
common  type  of  the  disease  and  is  peculiar  to  young  children,  occurring 
more  frequently  during  the  first  few  years  of  life,  and,  as  a  rule,  in  those 
who  are  illv  cared  for  and  poorly  nourished.  It  is  the  lichen  urticatus, 
strophulus,  varicella  prurigo,  and  infantile  urticaria,  etc.,  of  various 
writers.  Not  infrequently  it  is  mistaken  for  the  rare  disease  prurigo 
of  Hebra.  It  is  an  obstinate  form  of  urticaria  and  generally  worse  in 
summer.  The  lesion  is  a  papule,  induced  by  inflammatory'  changes 
supervening  upon  or  coexisting  with  the  serous  exudate  in  the  skin; 
capped  at  times,  if  the  inflammation  be  sufficiently  intense,  by  a  vesicle. 
The  eruption  occurs  in  successive  crops  as  millet  seed  to  small  pea  size, 
rosy  red,  acuminate  papules,  which  appear,  as  a  rule,  suddenly,  and 
instead  of  disappearing  in  a  few  hours  persist  several  days  or  longer. 
They  occur  more  particularly  on  the  upper  part  of  the  trunk  and  the 
external  surfaceof  the  arms  and  legs;  though  never  very  large  in  number, 
they  may  be  generally  dispersed  over  the  body  at  large  or  irregularly 
grouped,  and  confined  to  a  single  locality,  such  as  the  external  surface 
of  the  leg  or  anterior  surface  and  sides  of  the  thorax.  The  itching  is 
intense,  and  owing  to  the  scratching  the  tops  of  the  papules  l)ecome 
excoriated  and  small,  blackish  blood  crusts  are  formed  wliich,  falling 
after  a  few  days  or  so,  leave  pigmented  macules  which  slowly  disappear. 
Occasionally  vesiculation,  if  sufficiently  intense,  goes  on  to  the  formation 
of  builie,  constituting  the  bullou.'i  urticaria,  but  which,  however,  should 
be  looked  upon  more  as  a  comphcation,  and  a  rare  one,  than  forming 
a  distinct  variety  of  the  disease.  These  bullae,  when  occurring,  are 
generally  limited  to  the  hands  and  feet  of  children,  and  may  become 
pustular  through  unfavoral)ly  hygienic  conditions  favoring  infection. 

Etiology. — With  a  predispcjsition  as  a  groundwork  for  the  production 
of  an  urticarial  outbreak  the  secondary  causes  may  be  external  or 
internal.  Chief  among  the  former  are  insects  and  body  parasites,  and 
they  should  always  be  sought  for  as  a  cause  in  children.  The  main 
cause,  however,  in  children  is  some  derangement  of  the  digestive  tract, 
whether  temporary  and  brought  about  by  the  ingestion  of  some  improper 
article  of  diet,  or,  through  want  of  efficient  treatment,  allowed  to  persist 
and  develop  into  a  chronic  intestinal  catarrh.  Intestinal  worms  are 
frequently  a  cause  of  urticaria  in  children.  It  is  a  question  whether 
dentition  alone  plays  any  part  as  a  cause. 

Diagnosis. — The  diagnosis  of  the  ordinary'  form  of  urticaria  is  simple 
when  in  the  presence  of  the  characteristic  wheals;  in  their  absence 
the  story  of  the  sudden  appearance  and  disappearance  of  what  is  said 
to  "look  like  mosquito  bites"  will  generally  give  a  safe  working  clew 
to  the  trouble.  The  papular  form,  being  more  persistent,  may  resemble 
the  secondary  lesions  of  scabies  very  closely,  but  the  finding  of  the 
burrows  of  .scabies  and  its  lesions  between  the  fingers  and  in  the  other 


URTICARIA  935 

favorite  seats  where  urticaria  is  seldom  located  would  serve  as  a  guide  in 
the  right  direction;  except  in  infants  in  arms  scabies  does  not  occur 
on  the  face.  As  scabies  may  lead  to  an  urticaria  it  not  infrequently 
happens  that  the  two  are  associated,  when  the  difficulty  naturally  becomes 
greater  and  the  latter  be  overlooked  unless  by  inquiry  the  history  of 
wheals  is  eUcited.  When  vesiculation  takes  place  in  the  papule,  varicella 
may  be  resembled,  but  the  spindle-shaped  lesions  upon  which  the  easily 
ruptured  vesicle  of  varicella  is  seated  and  other  marked  features  would 
determine  the  difference.  In  case  of  a  severe  papular  urticaria  in  very 
early  infancy  it  might  be  a  question  of  the  rare  disease  prurigo,  and  this 
perhaps  could  only  be  determined  as  time  went  on  or  suggested  by  the 
severity  and  persistence  of  the  eruption.  Urticaria  does  not  run  into 
and  become  prurigo,  but  it  is  often  a  forerunner  of  the  latter  disease. 

Treatment. — In  the  instance  of  an  acute  attack  of  urticaria,  depending 
upon  the  ingestion  of  some  irritating  article  of  food,  an  emetic  may  be 
given  if  the  case  be  seen  early  enough;  this  often  will  cut  short  an  attack, 
and  nothing  further  is  necessary  beyond  careful  attention  to  diet.  If 
not  seen  in  time  it  is  best  to  administer  a  good  dose  of  castor  oil  and 
sweep  free  the  alimentary  canal.  In  the  more  established  forms,  where 
a  chronic  intestinal  catarrh  seems  to  be  at  fault,  a  strict  attention  to  the 
diet  is  of  paramount  importance.  Starting  out  with  a  purely  milk  diet 
for  a  varying  period  will  often  modify  the  eruption  of  a  papular  urticaria 
considerably;  then  the  choice  of  such  articles  of  food  that  best  agree 
will  be  a  matter  of  experiment,  more  or  less,  as  one  goes  along;  ordinarily 
sweets  should  be  cut  out  entirely,  and  starches,  such  as  oatmeal,  greatly 
limited.  Acid  fruits,  especially  strawberries,  should  be  avoided.  The 
bowels  should  be  kept  open  by  small  doses  of  calomel  or  castor  oil,  and 
a  plentiful  supply  of  water  should  be  drunk  throughout  the  day;  this 
alone  is  often  the  best  correction  against  constipation. 

Salicylate  of  soda  and  salol  will  be  found  useful  with  the  mineral 
acids,  after  meals,  for  the  associated  indigestion,  and  the  standby  rhubarb 
and  soda  is  most  helpful.  Antipyrin  and  quinine  in  fairly  large  doses 
will  be  found  efficacious  in  children  as  antipyretics,  especially  the  former, 
as  quinine  is  difficult  to  administer  to  young  cliildren  without  combining 
it  with  some  syrup  that  will  still  further  upset  the  stomach. 

For  the  reUef  of  itching  and  the  general  discomfort  local  measures 
can  hardly  be  dispensed  with,  and  for  this  purpose  demulcent  baths 
will  be  found  very  grateful  to  the  skin:  454  gm.  (1  pound.)  of  starch 
is  sufficient  for  the  ordinary  bath;  bran  can  be  added  to  the  water 
for  the  same  purpose.  Baths  should  be  warm,  not  hot,  and  the  body 
dabbed  dry  rather  than  rubbed,  and  then  thoroughly  dredged  with 
starch  powder  or  the  dolomol  powders,  which  adhere  best.  Spraying 
with  chloroform  is  excellent;  sponging  with  aromatic  vinegar,  diluted 
extract  of  witch-hazel,  or  a  saturated  solution  of  bicarbonate  of  soda 
will  be  found  useful.  The  lotions  should  alway  be  warmed  and  applied 
frequently.  A  good  application  is  a  solution  of  starch  boiled  to  about 
the  consistency  of  liquid  glue,  to  a  pint  of  which  has  been  added  4  gm. 
(1  dr.)   of  zinc  oxide,  and  8  c.c.    (2  dr.)  of  glycerin.     This  applied 


986  DISEASES  OF  THE  SKIN 

when  cool  will  often  afford  the  greatest  relief.    One  of  the  best  lotions 
is  the  following: 

^l— Acid,  carbol 3.20  gm.  (gr.  xlviij). 

Zinc,  oxid 5.54  gm.  (3iss). 

Glycerin 10.00  c.c.  (Siiss). 

Aq.  rosae q.  s.  ad  120.00  c.c.  (Siv) 

Dusting  powders  at  times  may  be  found  all  sufficient  in  mild  cases; 
one  of  the  best  is  the  dolomol-camphor,  10  per  cent.  Heavy,  irritating 
flannels  should  be  avoided  and,  if  possible,  soft  linen  worn  next  the  skin 
at  night.  The  coverings  shoukl  be  as  light  as  possible.  All  parasites 
should  be  carefully  searched  for  and  vigorously  eliminated. 

Fresh  air  and  tonics  and  attention  to  the  general  condition  will  in 
the  end  go  farther  toward  a  cure  than  most  efforts  in  this  direction. 


IMPETIGO. 

Impetigo  is  an  acute  inflammatory  disease  peculiar  to  childhood, 
characterized  by  the  rapid  formation  of  very  superficial,  easily  broken 
vesicles  or  blebs,  the  serous  or  seropurulent  contents  of  which  on  escaping 
coagulate  and  form  characteristic  granular,  yellow,  honey-like  crusts, 
without  areola,  covering  an  excoriated  surface  which  heals  without  the 
production  of  cicatrices.  It  is  contagious  and  sometimes  epidemic, 
autoinoculable  as  well  as  experimentally  so,  and  is  due  primarily  to  the 
action  of  a  special  microbe — the  streptococcus  of  Fehleisen.  The  fre- 
quency with  which  children  are  attacked  may  be  accounted  for  bv  the 
delicacy  of  the  skin  of  the  face,  the  favorite  seat  of  impetigo,  rather  than 
by  the  assumption  of  any  predisposing  cause  further  than  that  which 
may  be  instituted  in  them  through  their  poor  surroundings  and  general 
ill  nourishment,  leaving  them  with  poor  defence  against  attack.  In  this 
way  eczema  and  all  diseases  due  to  animal  parasites  may  be  said  to  be 
predisposing  causes  by  provoking  the  scratching  and  laceration  of  the 
skin  which  provide  a  port  of  entry  for  the  special  germ.  Though  im- 
petigo may  occur  in  any  child,  it  is  rare  and  only  accidental  in  those 
whose  surroundings  are  cleanly  and  whose  skins  are  properly  cared  for. 
It  is  a  self-limiting  disease  and  individual  lesions  have  an  evolution 
of  from  ten  days  to  two  weeks,  but  by  autoinoculation  new  lesions 
may  continue  to  appear  and  the  disease  be  thus  prolonged  indefinitely 
unless  means  be  taken  for  its  extinction. 

Symptomatology. — Constitutional  disturbance  is,  as  a  rule,  entirely 
wanting.  Contiguous  lymph  nodes  are  sometimes  swollen  and  painful. 
Itching,  while  not  a  regular  symptom,  may  be  present,  and,  though  slight, 
is  sufficient  to  cause  scratching  and  thus  fresh  inoculation  is  brought 
about.  The  primitive  lesion  of  impetigo  is  an  erythematous  spot  varying 
from  an  eighth  to  a  quarter  of  an  inch  in  diameter,  rapidly  increasing 
up  to  a  half  or  three-quarters  of  an  inch  and  very  slightly  if  at  all  raised 
above  the  surface  of  the  skin.  In  a  few  hours  the  uppermost,  horny 
layer  of  the  epidermis  covering  the  erythematous  spot  becomes  loosened 


PLATE  XXX. 


Impetigo. 


IMPETIGO 


987 


by  the  effusion  of  a  clear  serum,  which  later  may  become  slightly  cloudy, 
but  which  at  first  is  always  clear,  giving  rise  to  a  flattened,  irregular, 
partly  filled,  and  hence  wrinkled-looking,  superficial  bleb.  The  lesion 
now  looks  very  much  like  a  blister  caused  by  a  slight  burn  of  the  second 
degree.  These  two  stages  being  of  short  duration,  are  not  always  seen 
by  the  physician.  Very  soon,  owing  to  the  tliinness  of  the  covering 
membrane,  the  bleb  is  ruptured,  either  spontaneously  or  by  scratching,  and 
a  clear,  honey-Hke  serum  exudes  plentifully,  which,  coagulating,  covers 
the  area  of  the  bleb  with  a  granular,  heaped-up,  amber-like  crust  with  no 
surrounding  inflammatory  areola  (or  if  present,  an  extremely  slight  one), 
and  looking  as  if  "stuck  on"  the  sound  skin.  It  is  in  this,  the  more 
durable  stage,  that  the  disease  is  most  often  observed;  the  face,  more  or 
less  covered  with  the  discrete,  characteristic,  "stuck  on"  looking  crusts, 
which  may,  at  times,  form  quite  extensive  patches  from  agglomeration 
of  individual  blebs;  but  outlying  lesions  in  all  stages  may  generally  be 
found  in  the  neighborhood  of  the  larger  patches  after  the  disease  is  once 
estabUshed.  The  succeeding  stage  of  repair  follows  on;  the  crusts 
become  dryer  and  fall  off,  exposing  shiny  red  areas  exactly  correspond- 
ing to  the  deposed  crusts.  This  redness  gradually  disappears,  leaving 
no  cicatrix  or  subsequent  trace  of  the  disease.  While  the  face  is  the 
usual  site  of  impetigo  the  disease  occurs  behind  the  ears,  on  the  hands 
and  legs,  and  sparsely  and  abortively  on  the  body.  It  also  occurs  on 
the  scalp  in  disseminated  plaques,  matting  down  the  hair  and  subse- 
quently causing  its  fall,  which,  however,  is  only  temporary.  These 
postim'petiginous  bald  spots  are  sometimes  confusing,  being  taken  for 
lesions  of  alopecia  areata  or  evidences  of  ringworms;  they  present, 
however,  no  element  of  contagion.     (See  Plate  XXX.) 

There  is  a  rare  and  sporadic  form  of  impetigo  occurring  in  early  life 
which  differs  only  from  the  ordinary  type  in  that  the  lesions  are  larger, 
better  filled,  and  more  distinctly  bullous.  The  bullae  rise  abruptly  from 
the  healthy  skin  with  only  exceptionably  a  narrow  red  areola,  depending 
upon  the  purulence  of  the  contents.  They  are  small  in  number  and 
occur  most  frequently  over  the  buttocks,  thighs,  and  pubes,  though 
other  parts  of  the  trunk  and  limbs  may  be  attacked,  as  well  as  the  face. 
These  bullje  closely  resemble  ordinary  pemphigous  lesions,  and  in  all 
probabihty  the  cases  reported  from  time  to  time  of  acute  pemphigits  in 
infants  are  but  examples  of  this  bullous  type  of  impetigo. 

Diagnosis. — The  diagnosis  of  impetigo  presents  no  particular  difficulty 
in  view  of  the  characteristic  features  of  its  lesions — e.  g.,  their  discrete 
dissemination  over  exposed  surfaces — face,  head,  and  hands;  their  having 
no  inflammatory  areola  around  them,  and  the  inoculability  of  the  contents 
of  the  blebs  and  exudate  under  the  crusts.  Scabies  and  varicella  may 
be  readily  distinguished  from  impetigo  by  a  comparison  of  their  lesions 
with  the  above  points. 

Pustular  eczema  of  the  face  may  closely  resemble  impetigo  when  the 
lesions  of  the  latter  have  run  together  to  form  patches,  but  the  itching 
and  the  larger  and  inflammatory  patches  of  the  former,  with  green  or 
blackish  crusts,  will  aid  in  the  diagnosis;  furthermore,  there  are  nearly 


988  DISEASES   OF  THE  SKIK 

always  individual  typical  outlying  lesions  in  the  neighborhood  of  a  patch 
of  impetigo. 

Ecthyma  may  be  distinguished  by  the  pronounced  inflammatory 
areola/ indurated  base,  anil  lilackisli,  flat  crusts,  covering  distinctly 
ulcerated  surfaces.     Ecthyma  lesions  are  also  painful. 

Treatment. — The  treatment  of  impetigo  is  simple  and  most  eflficient: 
removal  of  the  crusts  ami  tiie  use  of  an  antiseptic  dressing.  The  majority 
of  the  crusts  may  be  loosened  and  detached  l)y  bathing  with  hot  water 
and  soap;  others  more  flrmly  adherent  may  be  first  soaked  in  sweet  oil 
overnight.  After  the  removal  of  the  crusts  is  accomplished  the  exposed 
surfaces  are  to  be  bathed  with  a  saturated  solution  of  boric  acid  in 
water  and  an  ointment  of  ammoniated  mercury  varying  from  0.65  gm. 
(10  gr.)  to  a  4  gm.  (1  dr.)  to  tlie  30  gm.  (1  oz.)  of  vaselin  or  rose- 
water  ointment  kept  constantly  applied.  At  times,  in  the  early  stage 
of  the  crusts,  after  their  removal  there  will  be  noticed  a  continued  exuda- 
tion of  serum  from  the  exposed  surfaces.  In  such  cases  dab  on  fre- 
quently during  the  day,  with  an  absorbent  cotton  tampon,  the  following 
lotion: 

9; — Camphor-water  to  saturation  and  filtered  .  .    600  gm.       (3xx). 

Sulphate  of  zinc 7gm.        (3jgr.  xlv). 

Sulphate  of  copper 2gm.       (Sss). 

It  is  important  that  the  camphor-water  be  well  filtered.  This  lotion 
will  sufticiently  dry  the  erosion  so  that  at  night  the  ammoniated  mercury 
ointment  may  be  applied.  Encountered  in  the  initial  vesicular  stage  the 
loose  covering  of  the  blebs  should  be  cut  away  with  scissors  and  the 
exposed  surfaces  lightly  frictioned  with  the  above-mentioned  lotion 
several  times  daily — no  further  treatment  being  necessary  in  these 
early  cases. 

SCABIES. 

Scabies  is  a  communicable  disease  of  the  skin  due  to  the  invasion  of 
the  upper  layers  of  the  epidermis  by  an  animal  parasite,  viz.,  the 
acarus  scabiei. 

It  is  no  longer  even  the  comparatively  rare  disease  in  this  country, 
as  has  been  but  recently  held,  for  it  has  become  now  a  fairly  common 
complaint,  and  this  is  due  rather  to  an  actual  increase,  as  shown  by 
clinical  statistics,  than  to  the  disease  being  more  frequently  correctly 
diagnosed. 

Symptomatology. — The  manifestations  of  the  disease  may  be  divided 
into  primary  and  secondary  lesions.  The  primary  lesions  constitute  the 
pathognomonic  characteristic  of  scabies  and  consist  of  the  burrow 
formed  by  the  female  acarus  as  she  travels  along  under  the  epidermis, 
feeding  and  depositing  her  eggs.  At  the  further  end  of  the  burrow  may 
be  discerned  a  small,  white  elevation,  denoting  the  female  acarus  beneath 
the  epithelium,  and  if  this  be  broken  carefully  and  the  point  of  a  needle 
inserted  she  may  be  withdrawn  clinging  to  the  end  of  the  needle  as  a 
tiny,  white  speck  just  about  visible  to  the  naked  eye.     The  burrows 


PLATE  XXXI. 


Scabies. 


SCABIES  989 

appear  as  fine,  M'hite,  grayish,  or  blackish  lines  slightly  elevated  above 
the  skin  surface;  they  may  be  straight  or  wavy  in  outline,  sometimes 
S-shaped  or  in  the  form  of  a  horseshoe,  and  vary  from  an  eighth  to  a 
half  an  inch  or  more  in  length.  The  acarus  chooses  by  preference  the 
parts  of  the  body  where  there  is  apt  to  be  both  warmth  and  moisture 
and  where  the  skin  is  most  delicate;  hence  the  burrows  are  found  in 
such  characteristic  places  as  between  the  fingers  and  along  their  sides 
near  the  web;  the  flexure  of  the  wrists,  particularly  at  the  inner  side;  the 
palms  of  the  hands,  feet,  and  buttocks  in  infants;  inner  side  of  the  thighs, 
anterior  border  of  the  axillae,  and  in  males  the  genitals.  The  face  is 
never  attacked  except  in  infancy,  and  then  generally  through  contact 
with  the  infected  breasts  of  the  mother.  These  burrows,  more  or  less 
pronounced,  with  a  white,  elevated  point  at  one  extremity,  constitute  the 
essential  and  pathognomonic  lesions  of  scabies;  and  were  it  not  for  the 
intense  itching  caused  by  the  irritation  in  the  skin  as  the  acarus  tunnels 
its  way  beneath  the  epidermis,  there  would  be  no  others.  It  is  due  to 
the  scratching  for  the  rehef  of  this  intense  itching  that  the  secondary 
lesions  supervene.  These  are  produced  not  only  at  the  sites  of  election, 
as  noted  above,  of  the  burrowing  acarus,  and  naturally  in  these  situations 
in  greater  abundance,  but,  pretty  generally,  through  reflex  irritation, 
over  the  whole  front  of  the  body,  barring  the  face,  except,  as  stated,  in 
infants,  and  consist  for  the  most  part  of  papules,  more  or  less  excoriated, 
and  vesicles,  vesicopustules,  and  pustules.  It  is  this  conglomeration  of 
lesions,  together  with  the  burrows,  that  constitutes  the  eruption  known  as 
scabies.  In  cases  of  some  standing  the  disease  may  be  compHcated  by 
ecthymatous  and  impetiginous  lesions,  furuncles,  etc.,  and  in  predisposed 
subjects  by  eczema  and  urticaria.  The  itching  is  most  pronounced,  and 
is  characteristically  intensified  at  night  when  the  patient  is  warm  in  bed 
— the  time  when  the  acarus  is  most  actively  at  work.  (See  Plate 
XXXI.) 

Diagnosis. — The  diagnosis  of  scabies  should  present  no  particular 
difficulty,  but  it  is  a  strange  fact  how  often  the  eruption  in  a  long- 
standing or  well-marked  case  is  mistaken  for  sypliilis,  to  which  it  would 
seem,  to  one  who  has  seen  anything  of  the  two  diseases,  not  to  bear  the 
faintest  resemblance.  Not  infrequently  a  patient  wall  be  encountered 
who,  presenting  a  body  absolutely  free  from  any  eruption,  will  complain 
of  itching  at  night,  this  itching  having  increased  during  two  or  three 
weeks;  a  close  inspection  may  or  may  not  reveal  the  burrows  on  the 
hands  or  elsewhere.  In  such  a  case,  suspicion  ha\ing  been  excited  by 
the  history  of  itching  at  night,  the  diagnosis  at  this  stage  may  be  made 
in  two  ways:  either  by  treating  the  hands  alone  for  two  or  three  days, 
with  a  resulting  discontinuance  of  the  characteristic  itching  at  night; 
or  by  letting  the  disease  run  on  and  waiting  for  the  eruption  produced 
bv  scratching  to  develop — it  surely  will  in  from  two  to  four  weeks  in  full 
feature.  Ordinarily  the  patient  is  presented  at  a  stage  when  the  acarus 
has  multiplied  and  been  transferred  to  other  parts  from  the  hands,  and 
the  secondary  eruption  is  already  present  in  its  polymorphic  character 
scattered  over  the  arms  and  hands  and  the  front  of  the  body,  from  a 


990  DISEASES  OF  THE  SKIN 

level  of  the  axilla?  to  tlio  middle  of  the  tliighs.  In  children  the  hands 
may  1h'  fairly  peppered  with  pustules,  vesicles,  and  papules,  more  pro- 
nounced at  the  web  of  the  Hngers,  where  a  pustidous  eruption  is  always 
strongly  indicative  of  scabies.  In  infants  the  eruption  may  appear  on 
the  face  and  head  from  contact  with  the  infected  breasts  of  the  UK^ther; 
likewise,  burrows  may  be  found  on  the  feet  and  buttocks  of  infants, 
having  been  transferred  from  the  hands  of  the  mother  or  nurse.  The 
skin  of  children  is  much  more  liahle  to  acute  iuHannnation,  and  in  them 
pustular  lesions  are  more  commonly  and  extensively  established, 
whether  directly  due  to  the  irritation  of  the  burrowing  parasite  or  to 
the  impetigo  and  ecthyma  induced  by  scratching.  In  a  well-marked 
case  the  scatter  in  g  oi  the  lesions,  chiefly  on  the  hands,  wrists,  axilhe,  and 
genitals  in  males,  will  distinguish  scabies  from  eczema,  for  there  is  more 
apt  to  be  grouping  of  the  lesions  into  patches  in  the  latter  disease. 

Treatment. — Scabies  is  an  entirely  and  readily  curable  affection;  only 
tempestuous  and  overtreatments  are  to  be  guarded  against,  for  often 
these  two  errors  set  up  a  resulting  eczema  or  dermatitis  more  difficult 
to  combat  than  the  original  trouble. 

Sulphur  is  the  chief  and  efficient  remedy.  In  the  following  combina- 
tion an  ointment  may  be  obtained  which  has  stood  a  long  test  as  regards 
its  efficacy  and  minimum  risk  of  resulting  irritation  of  the  skin,  both 
in  adults  and  children: 

{fc — Cretse  prsep., 

Sulph.  sublim aa     1.30  gm.  (gr.  xx). 

Bal.  Peru .        .61  c.  c.  (ITlx). 

Sapo.  virid 65  gm.  (gr.  x). 

Petrolat q.  s.  ad    30.00  gm.  (Sj). 

The  method  of  procedure  is  as  follows:  having  separated  an  ounce  of 
this  ointment  into  three  parts,  a  w^arm  bath  is  to  be  taken  at  bedtime, 
lasting  from  tw'enty  minutes  to  half  an  hour,  during  which  the  body  is 
well  soaped  and  scrubbed,  particular  attention  being  paid  to  the  hands, 
between  the  fingers,  and  folds  of  the  wrists.  In  mild  or  beginning  cases 
the  hands  alone  may  be  treated.  After  the  preliminary  bath,  in  an 
ordinary  case,  one  part  of  the  ointment  is  to  be  thoroughly  rubbed  all 
over  the  body,  working  it  well  in,  especially  between  the  fingers,  and 
over  the  waists,  axilhe,  and  genitals — the  rubbing  to  be  done  before  a 
fire  if  pos.sible.  Fresh  sheets  and  night  clothing  having  been  provided, 
the  anointed  patient  retires,  and  the  next  morning  is  to  omit  washing  the 
body,  and  to  put  on  fresh  underclothing.  The  following  night  a  second 
rubbing  is  to  be  made  without  a  preceding  bath,  the  third  night  the 
remaining  portion  of  the  ointment  is  to  be  utilized,  the  bath  again  being 
omitted.  The  fourth  morning  a  general  cleansing  bath  is  to  be  taken 
and  fresh  underclothing  put  on,  replacing  that  worn  during  the  course 
of  treatment.  Usually  these  three  successive  rubbings  will  complete  the 
cure.  At  any  rate  an  interval  of  some  days  should  be  made  before 
undertaking  another  coiu'se,  should  this  be  suggested  by  a  continuance 
of  the  itching,  and  a  soothing  lotion  used  to  allay  the  irritation,  due  either 
to  the  treatment  or  continuance  of  the  previous  inflamed  condition  of 


SCABIES  991 

the  skin,  consequent  upon  scratching.     The  following  lotion  is  best  for 
this  purpose: 

Jfc — Acid,  carbol 3.09  gm.  (gr.  xlviij). 

Zinc,  oxid 8.00  gm.  (5ij). 

Glycerin 9.25  c.c.  (5ijss). 

Aq.  calcis q.  s.  ad  120.00  c.c.  (Siv). 

After  a  few  days'  use  of  this  lotion  all  manifestations  will  have  sub- 
sided. Should  the  slight  itching  be  still  present  or  have  resumed — no 
attention  need  be  paid  to  itching  during  the  day  from  a  diagnostic  point 
of  view — a  second  course  may  be  instituted,  but  this  is  scarcely  ever 
necessary,  except  in  very  pronounced  and  long-standing  cases. 


IXDEX. 


ABDOMEN,  growth  of,  66 
Abiotrophic  diseases,  914 
Abiotrophy,  914 
Abscess,  circumtonsillar,  592 
treatment  of,  592 
of  brain,  940 

diagnosis  of,  943 
etiology  of,  940 
pathology  of,  941 
prognosis  of,  944 
symptomatology  of,  942 
treatment  of,  944 
ischiorectal,  810 

treatment  of,  310 
of  lung,  666 

diagnosis  of,  666 
physical  signs  of,  666 
symptomatology  of,  666 
treatment  of,  667 
retrophavNTigeal,  acute,  593 
course  of,  593 
symptomatology  of,  593 
treatment  of,  594 
tuberculous,  594 

treatment  of,  594 
Achondroplasia,  329,  854 

compared  with  cretinism,  854 
Addison's  disease,  850 

diagnosis  of,  850 
prognosis  of,  850 
symptomatology  of,  850 
treatment  of,  851 
Adenitis,  acute,  839 

diagnosis  of,  840 
pathology  of,  839 
symptomatology  of,  840 
treatment  of,  840 
chronic,  841 

diagnosis  of,  841 
symptomatology  of,  841 
treatment  of,  841 
syphilitic,  841 

tuberculous,   841.     See   Lymph  Nodes, 
Tuberculosa  of,  344 
Adenoid  growths,  587 

as  cause  of   bronchitis,  603 
dia.smosis  of,  589 
etiology  of,  587 
symptomatology  of,  588 
in  infants,  588 
in  older  children,  588 

63 


Adenoid  growths,  treatment  of,  589 
Adenoids,  587.     See  Adenoid  Growths,  587 
Adrenals,  the,  849 

hemorrhage  into,  849 

cardiac  failure  with,  688 
symptomatology  of,  849 
Air-tubes,  foreign  bodies  in,  680 
diagnosis  of,  681 
prognosis  of,  682 
symptomatology  of,  680 
treatment  of,  682 
Albuminaria,  773 

in  childhood,  773 

cyclic,  774.     See    Albuminaria,    Func- 
tional, llA 
in  early  infancy,  773 
functional,  774 

diagnosis  of,  775 
etiolog^-  of,  774 
pathology  of,  774 
prognosis  of,  775 
symptomatology  of,  774 
treatment  of,  776 
Amyloid  liver,  285 

diagnosis  of,  286 
pathology  of,  285 
symptomatology  of,  285 
treatment  of,  286 
spleen,  846 
Anemia,  815 

infantum         pseudoleukemia,         fvon 
Jaksch),    822.     See    P.-ieudoleu- 
kemia  of  Infants,  822 
Ivmphatica.    842.     See   Hodgkin's 
'  Disease,  842 
pernicious,  818 
blood  in,  818 
diagnosis  of,  819 
etiology  of,  818 
pathology  of,  818 
prognosis  of,  819 
.symptomatology  of,  818 
treatment  of,  820,  827 
secondary  or  simple,  816 

classification  of,  816 
diagnosis  of,  817 
etiology  of,  816 
hemoglobin  in,  816 
pathology  of,  816 
prognosis  of.  817 
spleen  in,  817 

993 


994 


INDEX. 


AiK'inia,    secondary   or    sinij)le,    svnijitoni- 
atolofiy  of,  810 
treatiiK'iit  of,  827 
Aneurysm,  7o8 
Ankylosioniuin  duodenale,  310.  See  Worms, 

Iiitcslinal,  31 U 
Antitoxin,  diplitiieria,  412.     Sec  Diphtheria, 

Antitoxin  in,  -il'l 
Anus,  prolapse  of,  307 

diagnosis  of,  308 
etiolo.sry  of,  308 
symptoniatolo.ey  of,  308 
treatment  of,  3U8 
Aortic  endocarditis,  70(1.      See  also  Heart 
I)it«-a.-r,  083 
regurgitation,    713.        See   also   Heart 
Disease,  (')8,3 
diagnosis  of,  714 
stenosis,  713.      See  also  Hrdrl  Hiseaur, 
683 
diagnosis  of,  714 
Aplithio,  Ik'dnar's,  177,  185 
Aphtlions   stomatitis,  177,     See    StoiiKililis, 

Ajihthoux,  177 
Api)endicitis,  '2!)4 
catarriial,  204 
diagnosis  in,  207 
'  Mood  in.  208 
etiology  of,  207 
pathology  of,  204 
eatai-riial,  204 
g-angrenous,  204 
ulcerative,  204 
prognosis  of,  300 
symptomatology  of,  205 
abscess  forming,  206 
acute  general  peritonitis,  207 
ulcerative,  206 
treatment  of,  300 
Arteriosclerosis,  750 
Arteritis,  acute,  759 

.sejJtic,  759 
Arthritis  (leformans,  582 
diagnosis  of,  583 
pathology  of,  582 
prognosis  of,  583 
Still's  form  of,  584 
symptomatology  of,  582 
treatment  of,  583 
multiple  secondary,  578 

acute  osteomyelitis  causing, 

579 
prognosis  of,  579 
therajjcutics  of,  580 
treatment  of,  576 
Ascaris   lumbricoides,    316.       See    Worim, 

Intestinal,  310 
Ascites,  305 

symptomatology  of,  305 
treatment  of,  305 
Asphyxia  neonatorum,  34 
adrenalin  in,  38 
artificial  resjiiration  in,  36 
circulation  in,  35 
extnuiterine  34 
intrauterine,  34 


Asphyxia  neonatorum,  oxygen  in,  37 
])i'ngnosis  of,  38 
symptomatology  of,  34 
treatment  of  livid,  35 
of  pale,  35 
Asthma,  bronchial,  615 
pathology  of,  616 
symptomatology  of,  616 
thymic,  837 

diagnosis  of,  837 
treatment  of,  837 
treatment  of,  (516 
Ataxia,  Fried rcicli's,  914 
hereditary,  014 

diagnosis  of,  016 
etiology  of,  014 
})athology  of,  014 
prognosis  of,  016 
symptomatology  of,  015 
treatment  of,  016 
Atlire[)sia,  31)7.     See  Marasmus,  337 
Atrophy,    Infantile,    337.      See  Marasmus, 
337 
nniscular,  ])eroneal  type  of,  925 
etiology  of,  925 
j)ath()logy  of,  025 
prognosis  of,  026 
symptomatology  of,  025 
treatment  of,  026 

BASIC  meningitis,  posterior,  932 
Bednar's  aphtha?,  177, 185 
Bell's  palsy,  888 

diagnosis  of,  880 
prognosis  of,  800 
symptomatology  of,  889 
treatment  of,  800 
Birth  pressure,  41,  44,  45 

symptomatolcgy  of,  45 
treatment  of,  4(> 
Bladder,  spasm  of,  76(5.    See   \'esical  Spasm, 

766 
Blood,  800 

abnormal  wliite  cells  of,  812 
blood-dust  in,  812 
-plates  in,  812 
differential  counting  of,  809 
eosino])liilia,  815 
hemoglobin,  811,  813 
leucojienia,  815 
leukocytosis,  813 

in  diphtheria,  814 
in  meningitis,  814 
in  scarlet  fever,  814 
in  vai-cinia,  814 
in  whooping  cough,  814 
lymj)hocvtes  in,  813 
red  blood-cells  in,  800 

nucleated,   811 
mast-cells  in,  812,  815 
megaloblasts  in,  811 
myelocytes  in,  815 
noinioblasts  in,  811 
.significance  of  changes  in,  813 
white  blood  cells  in,  811 
Bones  of  head,  fractiu-e  of,  44 


INDEX. 


995 


Bothriocephalus   latus,    313.     See    Worms^ 

Intediiud,  310 
Boys,  growth  of,  76 

Brachial  paralysis,  48.     See  ParalysUy  Bra- 
chial, 4JS 
Brain,  abscess  of,  940 

diagnosis  of,  943 
etiology  of,  940 
pathology  of,  941 
prognosis  of,  944 
symptomatology  of,  942 
treatment  of,  944 
tmnors  of,  944 

pathology  of,  945 
symptomatology  of,  946 
Breast  iMilk.     See  Milk,  Breast,  93 
Bright's  disease,  781.     See  S^ephritis,  781 
Bronchi,  diphtheria  of,  397.   See  Diphtheria, 

385 
Bronchial  asthma,  615.     See  Asthma  Bron- 
chial, 615 
lymph  nodes,  tuberculosis  of,  351,  354, 

355,  356,  357 
pneumonia,  617.  See  Bronchopneimionia. 
617 
Bronchiectasis,  668 
diagnosis  of,  670 
etiology  of,  669 
physical  signs  of,  669 
prognosis  of,  670 
symptomatology  of,  669 
treatment  of,  670 
Bronchitis,  acute,  602 

diagnosis  of,  607,  626 
diarrhea  and,  603 
etiology  of,  603 
pathology  of,  603 
physical  examination  in,  606 
prognosis  of,  607 
symptomatology  of,  604 
teething  and,  603 
capillary,  604,  606 
diagnosis  of,  607 
prognosis  of,  607 
treatment  of,  607 

prophylactic,  608 
chronic,  609 

symptomatology  of,  609 
treatment  of, 
fibrinous,  610.      See  Bronchitis,  Plaatlc, 

610 
plastic,  610 

pathology  of,  610 
prognosis  of,  610 
symptomatology  of,  610 
treatment  of,  610 
Bronchopneumonia,  617 
bacteriology  of,  618 
complications  of,  626 
cough  in,  620 
course  of,  625 
diagnosis  of,  626 
diarrhea  in,  622 
empyema  in,  658 
etiology  of,  617 
histology  of,  619 


Bronchopneumonia,  incidence  of,  618 
meningitis  in,  626 
morbid  anatomy  of,  618 
nervous  symptoms  in,  622 
otitis  in,  626 
pathology  of,  618 
physical  signs  of,  622 
primary,  617 
pro.gnosis  of,  628 
secondary  to  bronchitis,  626 

diari-hea,  626 

diphtheria,  626 

influenza,  470 

measles,  625 

pulmonary  tuljerculosis,  627 

septic  states,  626 

syphilis,  626 

whooping  cough,  625 
sequelffi  of,  626 
symptomatology  of,  619 

primary,  619 

secondary,  620 
temperature  in,  621 
treatment  of,  628 

stimulants  in,  617 
varieties  of,  625 
with  empyema,  658 

lobar  pneumonia,  639 
tuberculous,  363 

chronic  form  of,  365,  366 

cough  in,  366 

physical  signs  of,  364 

subacute  form  of,  363 

CACHECTIC  purpura,  828.   See  Purpura, 
Cachectic,  828 
Calculus,  renal,  798 
vesical,  799 

diagnosis  of,  799 
prognosis  of,  799 
ti'catment  of,  799 
Carcinoma  of  spleen,  848.     See  Spleen,  Car- 
cinoma of,  848 
CancTum  oris  187.     See  Stomatitis,  Ganrjre- 

ntnia,  187 
Carditis,  acute,   696,  731.     See  also  Heart 
Disias'-,  6S3 
treatment  of,  731 
paleative,  732 
salicylate,  736 
chronic, 

anasarca  in,  738 
serum  treatment  of,  739 
severe  palpitation  and  pain  in,  738 
Catarrh,  gastroenteric,  340.     See   Gastroen- 
teric Catarrh,  340 
nasal,  acute,  585 

etiology  of,  585 
symptomatology  of,  585 
treatment  of,  586 
chronic,  587 

symptomatology  of,  587 
treatment  of,  587 
Catarrhal  appendicitis,  294.      See  Appendi- 
citis, 294 
diphtheria,  391.      See  JDiphiheria,  385 


996 


INDEX. 


Catarrhal    ileocolitis,   252.     See   Ileocolitis, 
2-")l 
iiidiieiiza,  408.     See  Injlucnza,  465 
stomatitis,    175.        See  ISlomatitis,    Ca- 
tarrhal, 175 
Cephalhematoma,  41 
etiology  of,  41 
internal  hematoma,  41 
treatment  of,  43 
CerebellniM,  tinnoi-s  of,  950 
diagnosis  of,  950 
l)rognosis  of,  952 
tieatment  of,  952 
surgieal,  952 
Cerebral  development,  arrested,  918 
diagnosis  of,  918 
pi'ognosis  of,  919 
treatment  of,  919 
hemorrhage,  95(5 

diagnosis  of,  957 
symptomatology  of  950 
treatment  of,  957 
infarction  in  rhenmatic  heart   disease, 

727 
inflnen/.a,  409 
palsies,  957 
sinus  thromhosis,  9.38 

diagnosis  of,  939 
pathology  of,  938 
jjrognosis  of,  940 
symptomatology  of,  939 
treatment  of,  940 
Cerebrospinal    meningitis,    ejiidemic,    462. 
See  Mrniii;)llii<,  Epidemic  ('irihyospinal,A(\2 
Cervical  lymph  nodes,  tnbercnlosis  of,  351, 
353.      See  Li/niph  yodcs,  Tuberculosis  of, 
344 
Chest,  growth  of,  0(5 
Chickenpox,  541.     See  Varicella,  541 
Chlorosis,  820 
blood  in,  820 
diagnosis  of,  821 
etiology  of,  820 
I)athology  of,  820 
prognosis  of,  821 
symptomatology  of,  821 
treatment  of,  821 
Cholera  infantum,  237 

diagnosis  of,  239 
etiology  of,  237 
hyiHidermoclysis  in,  240 
pathology  of,  237 
prognosis  of,  239 
prophylaxis  in,  239 
symptomatology  of,  238 
treatment  of,  239 
Chondrody.strophy  854.    See  Achondroplasia, 

854 
Chorea,  acute,  863 

complications  in,  866 
diagnosis  of,  866 
endocarditis  in.  866 
etiology  of,  863 
heail  disease  and,  695 
malignant  form  of,  668 
mild  cases  of,  865 


Chorea,  acute,  pathology  of,  864 
pericarditis  in,  80(5 
severe  cases  of,  865 
symptomatology  of,  864 
tieatment  of,  807 
electric,  870 

treatment  of,  870 
habit,  803 

diagnosis  of,  869 
symptomatology  of,  868 
treatment  of,  8(39 
major,  868 

diagnosis  of,  868 
orgj'.nic,  871 
j)rehemiplegic,  871 
progressive,  870 

diagnosis  of,  871 
treatment  of,  871 
Choreiform  diseases,  803 
Cirrhosis  of  liver,  286.    See  Liver,  Cirrhosis 

of,  280 
Coiic,  151 

in  nui-slings,  269 

pri))>hylaxis  of,  270 
symptomatology  of,  269 
treatment  of,  270 
renal,  798 
Colhijjse,  pulmonary,  611.      See  Pulmonary 

Collajisc,  (51 1 
Concussion  of  sjunal  cord,  908.     See  S]>inal 

Cord,  Concussion  of,  908 
Congenital  dislocation  of  hip,  52 

heart  disease,  688.     See  Heart,  Disease 

of,  083 
hypertrophy  of  pylorus,  221 
diagnosis  oi",  223 
etiology  of,  221 
pathology  of,  221 
juognosis  of,  223 
symptomatology  of,  222 
tieatment  of,  224 
infantile  stridor,  599 

jiathology  of,  599 
symptomatology  of,  599 
tieatment  of,  599 
syphilis,  00,  329,  335,  340,  563 
Congestion  of  livei,  2S4.     Hee  Liver,  Conyes- 
tlmi  of,  284 
of  spleen,  chronic  passive,  846 
Conjunctiva,  diphtheria  of,  398.    See  Diph- 
theria, 385 
Constipation,  chronic,  277 
diagnosis  of,  278 
etiology  of,  277 

anatomical,  277 
dietetic,  278 
functional,  277 
habitual,  278 
muscular, 
prognosis  of,  279 
treatment  of,  in  nui-slings,  279 
artificially  fed.  279 
diet  in, 

enemata  in,  279 
full  feeding  in,  279 
hygiene  in,  279 


INDEX. 


997 


Constipation,  chronic,  treatment  of,  in   nurs- 
lings, massage,  280 
suppositories  in,  2S0 
in  older  children,  280 
habitual,  150 
Convulsions,  reflex,  872 

prognosis  of,  873 
symptomatology  of,  872 
treatment  of,  873 
Cord,  spinal,  908.    See  Spinal  cord,  908 
umbilical,  38 

accidents  to,  38 
fungus  of,  40 
hemorrhage  of,  39 

treatment  of,  39 
infection  of,  40 

treatment  of,  40 
Cowpox,  545.     See  Vaccinia,  545 
Cows'  milk,  107.     See  MUk,  Cows',  107 
Cretinism,  851 

achondroplasia  compared  with,  854 
diagnosis  of,  853 
infantilism  compared  with,  853 
Mongolian  idiocy  compared  with,  853 
pathology  of,  851 
prognosis  of,  854 
rickets  compared  with,  854 
symptomatology  of,  852 
treatment  of,  854 
Croup,  diphtheritic,  403.     See  Diphtheria, 
385 
false.   595.     See  Laryngitis   Stridulosa, 

595 
spasmodic,  595.     See  Laryngitis  Stridio- 
losa,  595, 
Croupous  pneumonia,  629.     See  Pneumonia 

Croupous,  629. 
Cystic  degeneration  of  kidney,  807 

tumors  of  spleen,  848 
Cystitis,  771 

diagnosis  of,  772 
prognosis  of,  772 
symptomatology  of,  772 
treatment  of,  772 

DEGENERATIVE  nephritis,  acute,  779. 
See  Nephritis,  Acute  Degenerative,  779 
Development  and  growth,  61 

arrested  cerebral,  918 
Diabetes  mellitus,  856 
age  in,  857 
causes  of,  857 
coma  in,  858 
diagnosis  of,  859 
etiology  of,  857 
heredity  in,  857 
pathology  of,  857 
prognosis  of,  859 
prophylactic  diet  in,  860 
sex  in,  857 

symptomatology  of,  858 
treatment  of,  859 
urine  in,  859 
Diarrheal  diseases,  chronic,  263 
diagnosis  of,  260 
nervous  symptoms  in,  259 


Diarrheal   diseases,  chronic,    prognosis   of, 
260 
treatment  of,  261 
dietetic,  262 
general,  261 
hygienic,  261 
local,  263 
medicinal,  263 
Diarrheas  of  infancy  and  childhood,  242 
age  afiected  by,  242 
bacteria  in,  244 
care  of  children  during,  243 
constitutional     conditions    condu- 
cive to,  244 
mode  of  feeding  conducive  to,  242 
physiological  factors  in,  242 
season  of  prevalance  of,  243 
surroundings  conducive  to,  243 
simple,  245 

colliquative,  245 
drugs  as  cause  of,  246 
mechanical,  245 
nervous,  245 
Diet  from  fifteenth  to  eighteenth  month,  174 

twelfth  to  fifteenth  month,  174 
Digestion  of  casein,  91 

of  paracasein,  91 
Digestive    organs   and  digestion    in   child- 
hood, 196 
in  infancy,  196 
Dilatation  of  stomach,  219.     See   Stomach, 

Dilatation  of,  219 
Diphtheria,  385 

antitoxin  in,  412 

administration  of,  414 
dosage  of,  415 
effect  of,  412 

on  blood,  406 
chemical,  415 
on  larynx,  413 

on    occurrence    of    complica- 
tions, 414 
bacteriologv  of,  386 
blood  in,  391,  814 
catarrhal,  391 
of  conjunctiva,  398 
croup  in,  403 
diagnosis  of,  402 

bacteriological,  407 
clinical,  402 
of  ear,  399 

effect  of  hoi-se  serum  in,  416 
etiology  of,  385 
extubation  in,  422 
difBculties  of,  423 
indications  for,  422 
of  genitals,  398 
heart  disease  from,  390,  740 
intubation  in,  417 

feeding  of  cases  dunng,  423 
indications  for,  428 
instruments  for,  417 
method  of  performing,  420 
retained  tube  in,  423 
of  larynx,  394,  403 
mixed  infection  in,  391 


998 


INDEX. 


Diphtheria,  t.f  month,  186,  398 
of  nasil  cavity,  ;i'.)4,  404 
nervous  system  in,  399 
panilysis  in,  399 

l)athology  of,  389 
of  j>harynx,  392 
j)redis|K)sinj!;  factors  in,  380 
protfnosis  of,  4tio 
prophylaxis  of,  400 
pst'iido,  4'2") 

pseiiilonu-mhi-ane  of,  380 
piihnonary  li-sions  in.  400 
of  trachea  and  bronchi,  397 
traclieotomy  in,  423 

com])iications  in,  424 

effect  of,  424 

indications  for,  425 

treatment  after,  425 
treatment  of,  400 

local,  410 
urine  in,  392 
of  wounds,  499 
Diphtheritic  croup,  403 
stomatitis,  ]8(),  399 

tretitment  of,  186 
Dislocation,  congenital,  52 
of  spinal  cord,  910 

treatment  of,  910 
Disseminated   sclerosis,  912.     See  Scleroxin, 

Disfteviinated,  912 
Dysentry,  251.    See  Ileocolitis,  Acute,  251 
Dystropliy,  nniscular,  919 

Erb's  juvenile  type  of,  921 

etiology  of,  919 

pathology  of  919 

prognosis  of,  923 

pseudoyjiertrophic  form  of,  923 

sympthatology  of,  920 

treatment  of,  924 
Dysiiria,  766     See  Vesical  Spasm,  766 

EAR,  diphtlicria  of,  399 
injuries  at  birth  to,  45 
Ecthyi'na,  980 

diagnosis  of,  982 

symptomatology  of,  980 

treatment  of,  982 
Eczema,  969 

diagnosis  of,  974 

erythematous.  972 

etiology  of,  970 

ointment  for,  978 

papular,  il73 

prognosis  of,  975 

I)ustnlar,  973 

treatment  of,  975 

varieties  of,  972 

vesicular,  973 
E<lema  of  face  in  rheumatic  disease  of  heart, 
729.     See  also  Ilenrt  Disease,  683 

of  liuigs  in  rheumatic  disea.se  of  heart, 
729 
Edematous  laryngitis,  596.     See  LaryrKjilis, 

Edematoiix^  596 
Electric  choiea,  870.  See  Cfiorea, Electric,  870 


Emphysema,  613 
etiology  of,  613 

aciitc,  613 

chronic,  613 
histology  of,  ()14 
pathology  of,  614 
physical  signs  in,  614 
jtrognosis  of,  615 
in  pulmonary  tibi-osis,  676 
symptomatology  of,  614 

acute,  614 

chronic,  614 
treatment  of,  615 
Empyema,  ()53 

after  treatment  f)f,  664 
aspiration  in,  063 
ausiultalion  in,  ()('<0 
bacteriology  of,  654 
blood  in,  6()0 

bronchopneumonia  in,  658 
comjjlications  of,  657 
diagnosis  of,  659,  660 
dyspnea  in,  656 
etiology  of,  653 
incision  in,  663 
fever  in,  656 
location  of,  657 
lung  in,  654 
meningitis  in,  658 
morbid  anatomy  of,  654 
pathology  of,  654 
jiericarditis  in,  658 
physical  signs  of,  657 
prognosis  of,  662 
resection  in,  663 
scqueljc  of,  659 
skin  in,  656 

symi)tomatology  of,  655 
termination  of,  658 
treatment  of,  663 
with  tuberculosis,  658 
Encephalitis,  936 
diagnosis  of,  937 
etiology  of,  936 
pathology  of,  936 
symptomatology  of,  937 
treatment  of,  937 
Endocarditis,  697,  698,  705.    See  also  Heart 
Disease,  683 
in  acute  chorea,  866 
aortic,  706 

malignant,  721.      See  also  Heart  Dis- 
ease, 683 

diagnosis  of,  724 

from  ])yogenic  infection,  751 
etiology  of,  751 
prognosis  of,  752 
symptomatology  of,  751 
treatment  of,  752 

pathology  of,  721 

j>rognosis  of,  724 

symptomatology  of,  722 

treatment  of,  724 
mitral,  706 
Enlargement  of  spleen,  846 
Enteritis,  251.     See  Ileocolitis,  Acute,  251 


INDEX. 


999 


Enterocolitis,    251.     See    Ileocolitis,  Acut<\ 

251 
Enuresis,  757 

etiology  of,  767 

nocturnal,  883 

prognosis  of,  768 

symptomatology  of,  768 

treatment  of,  768,  883 
Epigastric  lymph  nodes,  tuberculosis  of,  351. 

See  Lymph  Nodes,  Tuberculosis  of,  344 
Epilepsy,  873 

aura  in,  874 

clonic  spasm  in,  874 

comatose  stage  in,  875  , 

diagnosis  of,  875 

grand  mal,  874 

petit  mal,  874 

prognosis  of,  875 

symptomatology  of,  874 

tonic  spasm  in,  874 

treatment  of,  875 
Erb's  juvenile  muscular  dystrophy,  921 
Erythema  infectiosum,  539 

diagnosis  of,  539 

etiology  of,  539 

prognosis  of,  540 

symptomatology  of,  539 

treatment  of,  540 
Erythematous   eczema,    972.     See    Eczema, 

'  972 
Eye,  injuries  at  birth  to,  45 

syphilis  of,  571 

II^ACE,  edema  of,  in  rlieumatic  disease  of 
'  heart,  729 

growth  of,  65 
injuries  at  birth  to,  44 
Facial  palsy,  888 

diagnosis  of,  889 
prognosis  of,  890 
symptomatology  of,  889 
treatment  of,  890 
paralysis.  47 
False  croup,  595.    See  Laryngitis  Stridulosa, 

595 
Fatty  liver,  284.     See  Liver,  Fatty,  284 
Febrile  influenza,  755 
Feeding,  breast,  90,  93 

weaning  in,  105 
in  difficult  cases,  158 

artificial  foods  in,  163 
condensed  milk  in,  162 
cream  and  whey  in,  160 
low  formula  in,  155 
peptonization  in,  159 
split  proteids  in,  158 
whey  in,  160 
after  first  year,  167 
from  five  to  eight  years,  174 
from  three  to  four  years,  174 
infant,  123 

adjuncts  to  digestion  in,  149 
after  first  year,  167 

bread  for,  170 
cereals  in,  169 
eggs  in,  171 


Feeding,     infant,    after     first    year,    from 
eighteen  months  to  two 
years,  173 
fruits  and  their  juices  in, 

171 
meats  and  its  derivatives 
in,  170 
alkaline  diluents  in,  134 
attention  to  details  in,  148 
bicarbonate  of  soda,  130 
bottle  cosies  in,  140 
calculation  of  percentage  in,  128 
carbohydrates  in,  125 
cereal  diluents  in,  135,  137 
jellies  in,  138 
waters  in,  138 
certified  milk  in,  139 
choice  and  care  of  bottles  in,  140 

of  nipples  in,  140 
dextrinized  gruels  in,  13S 
diluents  in,   134 
fat  in,  125 

percentage  in,  130 
food  elements  in,  124 
interval  in,  143 
key  to  modification  in,  141 
lime-water  as  diluents  in,  135 
milk  dippei's  in,  131 

laboratories  in,    in,  135 
mineral  salts  in,  125,  l64 
number  of  feedings  in  24  lioui-s  in, 
144 
of  nights  feeding,  144 
oxygen  in  fresh  air  as  food  in,  149 
percentage  in,  128 
preparation  of  food  in,  139 
proteids  in,  125 
quantity  of  food  in,  142 
substitute,  123 
sugar  percentage  in,  133 
■  water  in,  125 
maternal,  89 
Fibrinous  bronchitis,  610.     See  Bronchitis, 

Plastic,  610 
Fibrosis    of    lungs,    C68.     See    Pulmonary 

Fibrosis,  668 
Fibrous    rheumatism,    chronic,    581.      See 

Rheumatism,  Chronic  Fibrous,  581 
Floating  spleen,  847 

Follicular  inflammation  in  acute  gastritis, 
210 
pharyngitis,  chronic,  194 

symptomatology  of,  194 
treatment  of,  194 
tonsillitis,  591 

diagnosis  of,  592 
symptomatology  of,  591 
treatment  of,  592 
Foreign  bodies  in  the  air  tulies,  680.     See 

Air  Tuhe.%  Foreign  Bodies  in,  680 
Fourth  disease,  538 
Fractures  at  birth,  44,  50 
diagnosis  of,  53 
symptomatology  of,  45 
treatment  of,  46,  53 
of  extremities,  50 


1000 


li^DEX. 


Fractures  of  spinal  cord,  910 

treatniont  of,  910 
Friedreich's  ataxia,  914 
Functional  aihiiininaria,  774.     See  Albumi- 

naria,  Funclional,  774 
Fungus  of  umbilical  cord,  40 

GANGRENE   of   lung,   (567.     See  Lumj 
Ganf/rene  of,  (i(')7 

in  rluMiinatic  disease  of  heart,  730 
Gangrenous  appendicitis,  294.     .See  Appe7i- 
(llritis,  -I'M 
stomatitis,    187,    531.     See    Stomatitis, 
Gangrenous,  187 
Gastralgia,  203 

diagnosis  of,  204 
pathology  of,  204 
symptomatology  of,  204 
treatn)ent  for,  204 
Gastric  indigestion,  acute,  20') 
diagnosis  of,  206 
prognosis  of,  206 
symptomatology  of,  206 
treatment  of,  206 
Gastritis,  acute,  209 

diagnosis  of.  211 
etiology  of,  209 
follicular  inflammation  in,  210 
gastromalacia  in,  210 
membranous  inflamination  in,  210 
prognosis  of,  21 1 
symptomatology  of,  210 
treatment  of,  212 
chronic,  212 

diagnosis  of,  215 
etiology  of,  213 
pathology  of,  213 
prognosis  of,  215 
symptomatology  of,  213 
treatment  in,  215 
Ga.stroduodenitis,  acute.  283 
diagnosis  of,  283 
etiology  of,  282 
pathology  of,  283 
symptomatology  of,  283 
ti'eatment  of,  283 
Gastroenteric  catarrh,  840 
infections,  225 

bacteria  in,  227 
bacteriology  of,  227 
causes  of,  226 
heat  in,  226 
Shiga  bacillus  in,  227 
simple,  229 

diagnosis  of,  231 
diet  in,  232 
dilute  milk  in,  234 
etiolog}'  of,  229 
lavage  in,  236 
medication  in,  234 
pathology  of,  229 
prognosis  of,  231 
prophylaxis  in,  231 
stimulation  in,  236 
.symptomatology  of,  229 
treatment  of,  232 


Gastroenteric,  influenza,  469 

(iastromalacia  in  acute  gastritis,  210 

(Jenitals,  diphtheria  of,  398 

(Jeriiian  measles,  535.     i^ee  Rubella,  535 

Girls,  growth  of,  76 

Glandular  fever,  483 

diagnosis  of,  484 
symptomatology  of,  483 
treatment  of,  485 
Gonorrheal  stomatitis,  185 
urethritis,  7()1 

symptomatology  of,  762 
treatment  of,  7tJ2 
«  vidvovaginitis,  763 
diagnosis  of,  765 
prognosis  of,  765 
symptomatology  of,  764 
treatment  of,  766 
Griji,  465.     See  Lijfuenza,  465 
Gri])pe,  465.     See  Influenza,  465 
(irowth,  71 

of  boys,  76 
of  girls,  76 
of  special  parts,  65 

HABIT  chorea,  868.     See    Chorea,  Habit, 
868 
Head,  fractures  of  bones  of,  44 
growth  of,  65 

symptomatology  of  injui-y  to,  45 
treatment  of  injuries  to,  46 
Heart,  diseases  of,  683 

acquired  forms  of,  685 

in  acute  chorea,  695 

anemia     predisposing    cause     in, 

687 
athletics  and,  757 
bronchopneumonia  in,  729 
clinical  examination  in,  683 
congenital,  685,  688 
blood  in,  690 
cyanosis  in,  690 
diagnosis  of,  693 
prognosis  of,  694 
.symptomatology  of,  690 
from  syphilis,  755 
treatment  of,  695 
dilatation  in,  704,  708,  707 
acute  of,  708 

in  pneumonia,  637 
endocarditis  m,  697,  698,  705,  706, 

712,  713,  714,  715,721 
etiology  of,  685 
from  diphtheria,  686,  740 
diagnosis  of,  743 
management  of,  743 
pathology  of,  740 
prognosis  of,  743 
symptomatology  of,  741 
treatment  of,  743 
medicinal,  745 
from  influenza,  755 
diagnosis  of,  755 
prognosis  of,  755 
symptomatology  of,  755 
treatment  of,  755 


INDEX. 


1001 


Heart,  diseases  of,  from   scarlet   fever,  686, 
752 
diagnosis  of,  752 
symptomatology  of,  752 
from  suppiu-ative  infection,  746 

symptomatology  of,  703 
functional,  756 

diagnosis  of,  756 
in  renal  disease,  757 

treatment  of,  758 
treatment  of,  756 
hypertrophy  in,  717 
in  syphilis,  755 
nervous  influences  on,  688 
ovei'sti'ain  predisposing  to,  687 
peculiarities  of,  in  childhood,  685 
position  of  heart  in,  684 
predisposing  causes  in,  686 
pulse  in,  683 

renal  disease,  cause  in,  687 
rheumatic,  695 
chronic,  712 

diagnosis  of,  712 
ruptured      compensation 

in,  716,  717 
symptomatology   of,  716, 
717 
complications  of,  726 
diagnosis  of,  719 
edema  of  face  in,  729 

of  lungs  in,  729 
hyperprexia  and  gangrene  in, 
730 
prophylaxis  of,  730 
treatment  of,  730 
hypertrophy  of,  717 
infarction  in,  726 
cerebral,  727 
mesenteric,  727 
pulmonary,  727 
renal,  727 
splenic,  727 

symptomatology  of,  727 
treatment  of,  727 
multiple  serosities  in,  725 
nephritis  in,  739^ 
pathology  of,  696 
physical  signs  of,  726 
pleuropericarditis    and    pleu- 
risy in,  729 
prognosis  of,  719 
pulmonary   complications   of, 

729 
purpura  in,  730 
symptomatology  of,  703 
thrombosis  of  veins  in,  727 
diagnosis  of,  728 
treatment  of,  728 
treatment  of  chronic,  737 
salicylate.  736 
serum,  739 
endocarditis  chronic.  753 

malignant,  754 

multiple  serosities,  754 
pericarditis,  753 
examination  of,  683 


Heart,  multiple  valvular  lesions  of,  715 
diagnosis  of,  715 
ruptured  compensation  of,  717 
course  of,  719, 
dilatation  and  hypertrophy  of, 

717 
physical  signs  of,  718 

in  aortic  lesions,  718 

in  mitral  lesions,  718 

regurgita  t  i  o  h  , 

71 8_ 
stenosis,  719 
symptoms  of,  in  aortic  disease, 
717 
in  mitral  disease,  718 
tuberculous,  753 
Hematoma,  internal,  41 
Hematuria,  77G 

diagnosLs  of,  777 
treatment  of,  777 
Hemiplegia,  spastic,  957.     See  Spastic  hemi- 
plegia, 957 
Hemophilia,  833 

diagnosLs  of,  834 
etiology  of,  833 
pathology  of,  834 
prognosis  of,  835 
symptomatology  of,  834 
treatment  of,  835 
Hemorrhage  cerebral,  956 
diagnosis  of,  957 
symptomatology  of,  956 
treatment  of,  957 
intercranial,  953 

etiology  of.  953 
of  spinal  cord,  908 
prognosis  of,  909 
symptomatology,  909 
treatment  of,  909 
sulxlural,  953 

diagnosis  of,  955 
treatment  of,  955 
of  umbilical  cord,  39 
treatment  of,  39 
Hemorrhoids,  310 

treatment  of,  310 
Henoch's  purpura,  931 
Hereditary  syphilis,  563 
Herpes,     177.        See    Stofinatitis    Aphthous 

177 
Herpetic  stomatitis,  177 
Hodgkin's  disease,  352,  842 
diagnosis  of,  842 
etiology  of,  842 
leukemia  in,  843 
pathology-  of,  842 
symptomatology  of,  842 
treatment  of,  843 
tuberculosis  in,  843 
Hydrocephalus,  325,  964 
internal  acute,  965 

diagnosis  of,  967 
etiology  of,  965 
symptomatology  of,  965 
treatment  of,  967 
chronic,  967 


1002 


IXDKX. 


Hydrocephalus,  internal,  clinmic,  (lia<,'Ti()sis 
of,  IKiS 
sym])t()niatoloji:y  of,  IXiT 
treatment  of,  S)Os 
Hydronephrosis,  80;") 
etiolof^y  of,  80") 
patli()l().i,'y  of,  80") 
j>rognosis  of,  80") 
syniptoinatoloiiy  of,  805 
treatment  of,  805 
Hygiene,  71 

of  infaTit,  fil 
iinrstTv,  (11 
nvpL'rpvri'xia  ni  rlicumalif  disease  of  licarl, 

780 
IlypcTtropliy  of  pylorus,  eoni^enital,  I'lil 
diagnosis  of,  '2'S>\ 
etiolofjy  of,  221 
pathology  221 
prognosis  of,  22;> 
symptomatology  of,  222 
tieatment  of,  224 
of  tonsil,  chronic,  51)2 

treatment  of,  51)2 
ITy))odermoclysis,  2-10 
Hysteria,  87(r 

diagnosis  of,  879 

etiology  of,  87(5 

mental  symjitoms  of,  877 

motor  manifestations  of,  877 

sensory  manifestations  ol',  877 

symptomatology  of,  877 

visceral,  878 
treatment  of,  870 

ICTERUS,  288.     See  Jaiuxlirr,  28S 

1      in  new  horn,  00 

Idiocy,  amaurotic  family,  91S 

Mongolian,    compared    with  cretinism, 
853 
Ileocolitis,  acute,  251 

pathology  of,  252 
catarrhal,  252 

ulcerative,  25.') 
jiseudomembninous,  253 
idcerative,  252 
syni})tomatology  of,   255 
ordinary  ty[)e  of,  257 
severe  ty])e  of,  255 
subacute  type  of,  258 
chronic,  203 

<liagnosis  of,  2t)(5 
etiology  of,  203 
])athology  of,  204 
])rognosis  of,  2()0 
symptomatology  of,  205 
treatment  of,  207 
dietetic,  207 
local,  208 
medicinal,  208 
Impetigo,  086 

diagnosis  of,  987 
symj)tomatology  of,  980 
treatment  of,  988 
Indigestion,  gastric,  acute,  205 
diagnosis  of,  206 


Indigestion,  gastric,  acute,  prognosis  of,  200 
symptomatology  of,  200 
tivatnient  of,  200 
chronic,  212, 

diagnosis  of,  215 
etiology  of,  213 
jiathology  of,  213 
)irognosis  of,  215 
symptomatology  of,  215 
treatment  of,  215 
intestinal  acute,  24() 

diagnosis  of,  248 
etiology  of,  246 
pathology  of,  247 
])rognosis  of,  249 
proi)hylaxis  of,  249 
symptomatology  of,  247 
treatment  of,  249 
chronic,  270 

etiology  of,  270 
pathology  of,  271 
symptomatology  of,  271 

in  older  children,  273 
treatment  of,  274 
in  infants,  274 

diluted  milk  in,  275 
lavage  in,  270 
in  older  children,  276 
Infant,  baths  of,  82 
bladder  of,  03 
care  of  at  birth,  21 
circulation  of,  01,  02 
changes  at  birth  in,  01 
clothing  of,  83 
disturbances  of,  102 

during  nursing  of,  100 
exercise  for,  85 

feeding  of,  123.  See  Feeding,  Infant,  123 
intestines  of,  03 
liver  of,  03 

nniscular  system  of,  04 
normal,   17 

blood  of,  18 
circulation  of,  19 
feeding  from  bii'th  of,  144 
influence  of  luu'sing  on,  21 
kidney  action  of,  19 
respiration  of,  19 
size  and  weight  of,  17 
stomach  and  intestines  of,  20 
temperature  of,  19 
umbilicus  of,  18 
urine  of,  19 
weight  of  organs  of,  20 
pi'ematnre,  22 

basket  for,  27 

care  of  intestines  of,  32 

dress  of,  24 

feebleness  of,  22 

feeding  of,  28 

gavage  for,  29 

incu})at()i-  for,  22 

inunction  for,  29 

prognosis  of,  33 

stimulation  of,  28 

susceptibility  to  drugs  of,  23 


INDEX. 


1003 


Infant,  premature,  treatment  of,  23 
weakness  of,  23 
weight  of,  32 
shoes  for,  84 
sleep  of,  86 
special  senses  of,  63 
speech  of,  6-1 
stomach  of,  63 
Infantile  stridor,  congenital,  599 
pathology  of,  599 
symptomatology  of,  599 
treatment  of,  599 
Infantilism  compared  with  cretinism,  853 
Infarcts,  uric  acid,  21,  798 
Infection  of  newborn,  53 

gastroenteric,  225 
of  umbilical  cord,  40 

treatment  of,  40 
Inflammation, follicular,in  acute  gastritis,210 

membranous,  in  acute  gastritis,  210 
Influenza,  465 

bacteriology  of,  405 
bronchopneumonia  in,  470 
catarrhal  form  of,  468 
cerebral  form  of,  469 
complications  and  secpielse  of,  470 
course  of,  471 
diagnosis  of,  470 
ear  disease  in,  470 
etiology  of,  467 
febrile  form  of,  408 
gastroenteric  form  of,  469 
heart  disease  from,  755 
pathology  of,  4()S 
prognosis  of,  471 
symptomatology  of,  468 
treatment  of,  471 
in  young  infants,  409 
Inguinal  scrofula,  351 
Intracranial  hemorrhage,  953 
Intranatal  infection  of  newborn,  55 
Interstitial    nephritis,    chronic,    793.      Sao 
Nephritis,  Chronic  Interstitial,  793 
neuritis,  886 
Intestinal  cases,  feedmg  in,  157 

parasites,  310.     See  Worms,  310 
Intestine,  tuberculosis  of, 
diagnosis  of,  372 
pathology  of.  370 
prognosis  of,  373 
symptomatology  of,  372 
treatment  of,  373 
Intubation,  417 
Intussusception,  287 
diagnosis  of,  291 
etiology  of,  287 
pathology  of,  288 
prognosis  of, 
symptomatology  of,  290 
treatment  of,  292 
inflation  in,  292 
laparotomy  in,  293 

JAUNDICE,  282,  283 
fj     diagnosis  of,  284 

of  newborn,  idiopathic,  60 


Jaundice,    of  newborn,  secondary,  60 
treatment,  60 
symptomatology  of,  284 
treatment  of,  284 

KIDNEY,  cystic  degeneration  of,  807 
disease   of,    799.      See    Nephritis, 
779 
malposition  of,  807 
movable,  807 

diagnosis  of,  807 
etiology  of,  807 
symptomatology  of,  807 
treatment  of,  8U8 
tuberculosis  of,  804 
diagnosis  of,  804 
patiiology  of,  804 
pi-ognosis  of,  804 
symptomatology  of,  804 
treatment  of,  804 
tumors  of,  800 
benign,  800 
diagnosis  of,  802 
etiology  of,  800. 
malignant,  800 
prognosis  of,  803 
symptomatology  of,  800 
cachexia  in,  801 
hematuria  in,  801 
pain  in,  801 
urine  in,  801 
treatment  of,  803 
surgical,  803 
urine  in,  801 

LACTATION,  diet  for  mother  during,  98 
exercise  for  mother  during,  99 
hygiene  for  mother  during,  99 
management  of,  97 
schedule  of,  97 
Laryngismus  stridulus,  598 

symptomatology  of,  598 
treatment  of,  598 
Laryngitis,  acute,  595 

diagnosis  of,  596 
edematous,  596 
etiology  of,  595 
stridulosa,  595 

treatment  of,  597 
symptomatology  of,  595 
treatment  of,  597 

severe  cases  of,  597 
chronic,  597 
Larynx,  diphtheria  of,  394,  403.    See  Biph- 
t  her  in 
new  growtlis  of,  599 
papilloma  of,  599 
treatment  of,  600 
Lnvage,  206 
Lead  poisoning,  335 
Ijcukemia,  823 

developed  stage  of,  825 
diagnosis  of,  825 
etiology  of,  823 
lymphatic  form  of,  824,  825 
pathology  of,  824 


1004 


INDEX. 


Leukemia,  prognosis  of,  826 
splei'ii  in,  S'_'U 

splfn()iii\H'l()<i:fnous  form  of,  824 
synii)t()iii:it(iluf,'y  of,  825 
treatnu'nt  of,  827 
Lithiasis,  7i>7 

renal  i-aictilus  in,  798 

colic  in,  798 
uric  acid  infarcts  in,  798 
vesical  calcnhis  in,  799 
(lia'>:n()sis  of,  799 
jn'of^nosis  of,  799 
treatment  of,  799 
Liver,  amyloid,  285 

diaf(nosis  of,  281) 
pathology  of,  285 
symptomatology  of,  285 
treatment  of,  285 
cirrhosis  of,  28(5 

etiology  of,  280 
pathology  of,  286 
prognosis  of,  287 
symptomatology  of,  286 
treatment  of,  287 
congestion  of,  284 

symptomatology  of,  284 
treatment  of,  284 
fatty,  284 

pathology  of,  284 
symjjtomatology  of,  285 
treatment  of,  285 
rare  affections  of,  287 
syphilis  of,  564,  570 
Lobar    pneumonia,    629.     See    Pneumonia, 

Cranpoiis,  629 
Luml)ar  puncture,  382. 
Limg,  abscess  of,  666 

diagnosis  of,  666 
physical  signs  of,  6(]{j 
symptomatology  of,  666 
treatment  of,  667 
collapse  of,  611.  8ee  Pulmonary  C'oU  j>x  ; 

611 
in  childhood,  (JOl 
edema  of,  in  rheumatic  disease  of  heart, 

729 
examination  of,  (iOl 
fibrosis  of,  668.    See  Pulmnnan/  Fibrn  ■!.■<, 

668 
gangrene  of,  667 
etiology  of,  667 
operation  for,  668 
pathology  of,  667 
physical  signs  of,  668 
symptomatology  of,  668 
treatment  of,  668 
tuberculosis  of,  .344 
Lymph  nodes,  inflannnation  of,  839.     Sl'c 
Adenilit,  839 
tuberculosis  of,  344,  357 

bronchial, 351,354,355,3".6.:;57 
cervical,  351,  353 
insenteric,  351 
diagnosis  of,  369,  372 
generalized,  352,  357,  358 
mesenteric,  351 


Lvmi)h  nodes,  tuberculosis  of,  pathology  of, 
372 
physical  signsof,  355,  356 
pressure  signs  from,  350 
prognosis  of,  358,  373 
symptomatology  of,  353, 
'  372 

treatment  of,  373 
Lymphatic     leukemia,     824.        See     Leu- 
kemia, 823 


M 


Ma 
Mil 


Me: 


ALAKL\,  453 

albuminuria  in,  459 

blood  in,  454 

cachexia  of,  453 

complications  in,  459 

diagnosis  of,  459 

etiology  of,  453 

foi-m  of,  454 

irregular,  458 
pernicious,  459 

mode  of  infection  in,  454 

nephritis  in,  459 

parasite  of,  454 
form  of,  454 

paroxysm  of,  457 

pathology  of,  455 

spleen  in,  459 

symptomatology  of,  456 

treatment  of,  4(10 
Iformation  of  sjjinal  cord,  926 
Ijjosition  of  kidney,  807 
rasmus,  337 

blood  in,  339 

diagnosis  of,  339 

diet  in,  341 

etiology  of,  337 

gastroenteric  infection  in,  337 

hygiene  in,  341 

])athology  of,  337 

l)rognosis  of,  340 

symptomatology  of,  338 

temperature  in,  339 

treatment  of,  340 

wasting  in,  338 
isles,  519 

angina  in,  528 

clinical  types  of,  521 

coiiqilications  and  sequelfe  of,  529,  530, 
531 

conjunctivitis  in,  528,  530 

des(|uamation  in,  522,  528 

diarrhea  in,  530 

etiology  of,  519 

erui)tion  of,  522,  627 

hemorrhagic,  524,  528 

invasion  of,  525 
Koplik's  spots  in,  523 

laryngitis  in,  529 
malignant  type  of,  524,  528 
mild  type  of,  523 
ordinary  type  of,  521 
otitis  m,  5.30 
]>atiiology  of,  521 
period  of  incubation  of,  520 
of  infection,  520 


INDEX. 


1005 


Measles,  pharyngitis  in,  529 
pleurisy  in,  529 
pneumonia  in,  529 
prognosis  of,  531 
prophylaxis  in,  532 
pulse  in,  527 
recurrence  of,  52-1 
relapse  in,  524 
severe  type  of,  524,  528 
sources  of  infections  in,  520 
symptomatology  of,  525 
temperature  in,  522,  527 
treatment  of,  532 
tuberculosis  after,  530,  532 
Mediastinal  scrofula,  351,  358 
Membi-anous    inilammarion    in    acute   gas- 
tritis, 210 
Meningitis,  929 

epidemic  cerebrospinal,  462 
blood  in,  814 
diagnosis  of.  464 
lumbar  puncture  in,  464 
pathology  of,  462 
prognosis  of,  464 
symptoms  of,  462 
treatment  of,  465 
etiology  of,  929 
pathology  of,  929 
posterior  basic,  932 

diagnosis  of,  933 
prognosis  of,  935 
symptomatology  of,  932 
treatment  of,  935 
stage  of  chronic  adhesion  in,  931 
of  congestion  in,  930 
of  effusion  in,  930 
symptomatology  of,  931 
tuberculous,  379 

diagnosis  of,  382 
etiology  of,  3/9 
lumbar  puncture  in,  382 
pathology  of,  380 
p]'Ognosis  of,  384 

stage  of  coma  and  paralysis  in,  381 
of  inflammatory  irritation  in, 

380 
of  invasion  of,  380 
symptomatology  of,  380 
treatment  of,  384 
Mesenteric  infarction  in   rheumatic   heart 
disease,  727 
lymph  nodes,  tuberculosis  of,  351.     See 
"  Lymph  Nodes,  Tuberculosis  of,  344 
Milk,  breast,  abnormalities  of,  101 

automatic  adjustment  of,  94 
colostrum  of,  93 
composition  of,  93,  95 
examination  of,  95 
fat  of,  96 

influence  of  drugs  on,  1 03 
of  illness  on,  104 
of  menstruation  on,  103 
of  pregnancy  on,  lii3 
microscopic  examination  of,  97 
nervous  influences  on,  104 
proteids  of,  91,  86 


MOk,  breast,  table  of,  126 
cows',  107 

bacteria  in,  110 

of  lactic  acid  in,  116 
casein  of,  107 

certified  rule  for  producing.  111 
changes   produced   by   high  tem- 
perature in,  121 
comparison   of    sterilization    and 

pasteurization  of,  120 
composition  of,  107 
cream  of,  122 

and  whev  mixtures,  161 
fat  of,  109      "_        _ 
influence  of  epidemic  on,  115 
pasteurization  of,  118 
necessity  of,  121 
preservation  of,  117 
proteids  of,  107 
sterilization  of,  120 
sugar  of,  108 
table  of,  126 
variations  of,  108 
whey  mixtures  from,  161 
laboratories  for  preparing,  164 
modified,  127 

use  of,  later  than  birth,  147 
woman's,  table  of,  126 
Miti-al  regurgitation,  712.     See  also  Heart 
Disease,  683 
diagnosis  of,  713 
symptomatology  of,  712 
stenosis,    713.     See  also  Heart  Disease, 
683    _ 
diagnosis  of,  715 
Mongolian  idiocy  compared  with  cretinism. 


MorbiUi,  519.     See  Measles,  519 

Morbus  ceruleus,  690 

Mouth,  disease  of,  175.     See  Stomalilis,  175 

diphtheria  of,  186,  398 
Movable  kidnev,  807.     See  Kidne>j,  Movable, 

807 
Multiple  sclerosis,  912.     See  Sclerosis,  Dis- 
seminated, 912 
serosities,  725 

diagnosis  of,  726 
prognosis  of,  726 
treatment  of,  726 
Mumps,  480 

bacteriology  of,  480 
complications  of,  482 
etiology  of,  480 
incubation  of,  480 
occurrence  of,  480 
pathology  of,  480 
prognosis  of,  482 
symptomatology  of,  480 
treatment  of,  482 
Muscular  atrophy,  925.     See  Atrophy,  Mus- 
cular, 925 
dvstrophv,  919 

Erb's  juvenile  type  of,  921 
etiology  of,  91 9 
pathology  of,  919 
prognosis  of,  923 


1006 


INDEX. 


Musriihir    (lyslrojiliy,    jjscudoliyportropliic 
loriii  of,  \yi'.\ 

syini)t(>iii:»t<il(ii;y  of,  t»20 

treatment  of,  '.'24 
Mycotic    stonuititis,    182.      See  Slotimtllis, 

'Miirolic,  182 
Myelitis,  acute,  8!l() 

clia,<,niosis  of,  899 

etiology  of,  890 

l)ath()l(V'y  of,  89G 

lirojjnosis  of,  900 

treatment  of,  i)00 
Myucanlial  faiinre,  acnte  riieumatic,  721 
See  also  lli-url  1  disease,  ()8i! 

diagnosis  of,  725 

treatment  of,  72-") 
Myocarditis  702,  710.     .See  also  Ilcurl  />/,-.- 

ea.te,  ()88 
^Myocardium,  the,  702 
Myxedema,  851.     See  Cniiiiisni,  851 

NASAL  catarili,  5S5.   See  Caldirli,  yitsal, 
585 
cavity,  dii)litlicria  of,  :VM,  401 
Nephritis,  acnte,  781 

degenerative,   779 
diagnosis  of,  780 
etiology  of,  780 
l>athology  of,  780 
prognosis  of,  780 

in  scarlet  fever,  504 
symptomatology  of,  780 
treatment  of,  7.SI 
diagnosis  of,  7.S() 
etiology  of,  78] 
patliology  of,  782 
prognosis  of,  78(j 
symptomatoh)gy  of,  782 
treatment  of,  787 
tubular,  782 
urine  in,  783 
chronic,  739 

heart  in,  757 
interstitial,  79;> 

diagnosis  of,  795 
etiology  of,  794 
prognosis  of,  795 
symptomatology  of,  794 
treatment  of,  79(; 
nrine  in,  795 
parenchymatous,  790 
diagnosis  of,  791 
etiology  of,  790 
pathology  of,  790 
prognosis  of,  791 
renal  decapsulation  in,  792 
symptomatology  of,  791 
treatment  of,  792 
surgical,  792 
nrine  in,  791 
in  rheumatic  heart  disease,  730 
Nervous  diseases,  orgjinic,  885 
system,  diseases  of  the,  8(il 
functional,  863 

methods  of  examinatif)n  of,Sr)l 
electricity  in,  862 


Nervous  system, diseases  of,  methods  of  exam- 
ination,motor  po\ver,862 
reflexes,  hOl 

abdominal,  8G2 
Achilles,  861 
biceps,  862 
chin,  802 
cremasteric,  862 
eye,  862 
knee,  862 
triceps,  802 
sensation,  862 
Neurasthenia,  881 
diagnosis  of,  881 
symjitomatoiogy  of,  881 
treatment  of,  8S2 
Neuritis,  885 

diagnosis  of,  887 
etiology  of,  885 
interstitial,  880 
parenciiymatous,  886 
]iathology  of,  885 
])rognosis  of,  887 
spe<ial  forms  of,  889 
symptomatology  of,  886 
treatment  of,  887 
Newborn,  icterus  in,  60 
infections  of,  53 
intranatal,  55 
postnatal,  55 
prognosis  of,  60 
symptomatology  of,  56 
ti-catment  of,  60 
o])hllialmia  of,  57 

treatment  of,  58 
pemphigus  in,  60 
syphilis  of,  55,  00 

treatment  of,  55,  58 
umbilicus  of,  50 
urine  of.  19,  770 

supi)ression  of,  771 
Nocturnal  enuresis,  883.     See  Ennrem's,  883 
Noma,   187.  See  Slomalilis,  Gmir/renous,  187 
Nose,   catarrh  of,  585.    See  Catarrli,  Acute 

Nasal,  585 
Nursery,  79 

cleanliness  in,  81 
heating  of,  79 
routine  in,  82 
temperature  of,  79 
ventilation  of,  80 

OUSTKTRK'AL  palsies,  47.     See  Puhies, 
OhMflrical,  47 
Ophthalmia  of  newborn,  57 
( )steosarcoma,  335 
Otitis  in  bronchopneumonia,  626 

in  <liphtheria,  399 

in  influenza,  470 

in  ini'aslcs,  530 

in  pi:emnonia,  638 

in  scarlet  fever,  502 

in  smallpox,  557 

in  syphilis,  57 

in  typhoid  fever,  441 

in  whooping  cough,  476 


INDEX. 


1007 


Oxyuris    vermiularis,    317.       See    Worms, 
Intestinal,  310 

PALSIES,  obstetrical  47,  48,  888 
treatment  of,  50,  888 
root,  891 
Palsy,  Bell's  (facial),  888 
diagnosis  oi',  889 
prognosis  of,  890 
symptomatology  of,  889 
treatment  of,  890 
Papilloma  of  larynx.  559 
Paralysis,  birth,  47 
brachial,  48 

treatment  of,  50 
in  diphtheria,  399 
facial,  47 

spastic,  hereditary,  916 
Paramyoclonus  multiplex,  883 

treatment  of,  883 
Paraplegia,  spastic,  957,  962 
Parasites,  intestinal,  310.   See  Worms,  Intes- 
tinal, 310 
in  spleen,  848 
Paratyphoid  fever,  445 
Parenchymatous  nephritis,  chronic,  790 
diagnosis  of,  791 
etiology  of,  790 
pathology  of,  790 
prognosis  of,  791 
symptomatology,  791 
treatment  of,  792 
surgical,  792 
urine  in,  791 
neuritis,  886 
Parotitis,  epidemic,  480.     See  Mumpn,  480 
infectious,  480 
in  typhoid  fever,  442 
Pemphigus  of  newborn,  60 
Pericarditis  in  acute  chorea,  866 
adherent,  714 
in  empyema,  658 
rheumatic,    701,  706.     Sse  also  Heart 

Disease,  693 
suppurative,  746.     See  also  Heirl  Dis- 
ease, 693 
diagnosis  of,  748 
etiology  of,  746 
pathology  of,  746 
prognosis  of,  750 
symptomatology  of,  748 
treatment  of,  750 
surgical,  750 
Pericardium,  adherent,  diagnosis  of,  714 
Perinephritis,  796 
diagnosis  of,  797 
etiology  of,  796 
pathology  of,  796 
prognosis  of,  797 
symptomatology  of,  796 
treatment  of,  797 
Perisplenitis,  847 
Peritonitis,  acute,  300 

diagnosis  of,  303 
etiology,  300 
lesions  of,  301 


Peritonitis,  acute,  pathology  of,  301 
prognosis  of,   303 
symptomatology  of,  302 
treatment  of,  303 
feeding  in,  304 
surgical  interference  in,  304 
chronic,  304 

diagnosis  of,  305 
etiology  of, 
pathology  of,  305 
symptomatology  of,  305 
treatment  of,  3()5 
tuberculous,  373 
ascitic,  374 
diagnosis  of,  377 
fibrous  form  of,  376 
pathology  of,  373 
prognosis  of,  378 
symptomatology  of,  373 
treatment  of,  378 
medical,  378 
surgical,  378 
ulcerative  form  of,  374 
Perleche,  184 

diagnosis  of,  185 
etiology  of  184 
lesion  of,  184 
treatment  of,  "185 
Pernicious  anemia,  818.  See  Anemia,  Perni- 
cious, 818 
Pertussis,  472.     See  Whooping  Cough,  472 
Pharyngitis,  acute,  191,  590 
diagnosis  of,  192 
pathology  of,  192, 
symptomatology  of,  192 
treatment  of,  193 
chronic,  591 

follicular,  194 

symptomatology  of,  194 
treatment  of,  194 
simple,  193,  591 

etiology  of,  193 
symptomatology  of.  193 
treatment  of,  194,  591 
symptomatology  of,  590 
treatment  of,  591 
Pliarvnx,  diphtheiia  of,  392.  See  Diphtheria, 

385 
Plastic  bronchitis,  610.  See  Bronchitis,  P'as- 

tic,  610 
Pleurisy,  dry,  646 

purulent,  653.    See  Empyema^  653 
serofibrinous,  646 

ausculation  in,  651 

diagnosis  of,  652 

etiology  of,  646 

palpation      and      percussion      in, 

650 
pathology  of,  647 
physical  signs  of,  650 
position  of  lesions  in,  649 
prognosis  of,  652 
symptomatology  of,  647 
temperature  in,  648 
termination  of,  651 
treatment  of,  652 


1008 


INDEX. 


Pneumonia,  bronchial,   617.     See   Bioncho- 
pneunwnid,  617 
croupous  (lobar),  629 
abortive,  637 
auscuhition  in,  635 
blood,  814 

bronchopneumonia  with,  630 
cerebral       symptoms       with, 

638 
clinical  varieties  of,  637 
complications  of,  638 
constipation  in,  631 
convulsions  in,  631 
cough  in,  631 
crisis  in,  633 
diagnosis  of,  640 
double,  637 
dyspnea  632 
etiology  of,  630 
hejirt  in,  ()37 
herjR's  lal)ialism,  632 
histology  of,  631 
morbid  anatomy  of,  631 
organs  in,  637 
otitis  In,  ()3'.) 
peritonitis  in,  640 
physical  signs  of,  634 
pleurisy  in,  ()3'J 
position  of  lesion  in,  636 
prognosis  of,  642 
pulmonary  iJl)rosis  after,  640 
purulent    pericaidilis  in,  640 
relapsing,  ()3)7 

resembling  scarlet  fever,  641 
resolution  in,  636 
sequelic  of,  640 
spreading    ()37 
symptomatology  of,  631 
temperature  in,  632 
treatment  of,  643 
urine  in,  632 
Pneumothorax,  665 

symptomatology  of,  665 
treatment  of,  665 
Poliomyelitis,  acute  anterior,  891 
diagnosis  of,  893 
etiology  of,  891 
pathology  of,  891 
prognosis  of,  894 
symptomatology  of,  892 
treatment  of,  894 
Polypus  of  rectum,  309.     See  Rectum,  Pohj- 

pux  of,  309 
Portal     lymph     nodes,      tuberculosis     of, 
351.     See    Lymph   Xodea,  TuberridoKia  of, 
344 
Posterior  basic  meningitis,  932.    See  Menin- 
gitis, Poaterior  Basic,  932 
Postnatal  infections  of  newborn,  55 
Pott's  disease,  902 

diagnosis  of,  904 
l&sions  of  spinal  cord  in,  902 
pathology  of,  902 
prognosis  of,  904 
symptomatology  of,  903 
treatment  of,  905 


Prehemiplcgic  chorea,   871.      See    Chorea, 

Pvfhi'inipleijic,  871 
Proctitis,  306 

diagnosis  of,  307 
etiology  of,  306 
pathology  of,  306 
symi)tomatology  of,  306 
trt'alment  of,  307 
Progiessive  chorea,  870.     See  Chorea,  Pro- 
gressive, 870 
Pseudodiphtheria,  425 
Pseudohvpertrophic    muscular    dystrophy, 

923 
Pseudoleukemia.  See  Hodglcins  Disease,  842 
of  infants  (von  Jaksch),  822 
blood  in,  822 
diagnosis  of,  823 
etiology  of,  822 
jiathology  of,  822 
svmptomatologv  of,  822 
tieatmenl  of,  823,  827 
Pseudomembranous     ileocolitis,    253.     See 

Ileoviililis,  251 
Puberty,  growth  at,  76 
PulmoiKiry  collapse,  611 
diagnosis  of,  (512 
etiology  of,  611 
symptomatology  of,  611 
treatment  of,  612 
complication    of  rheumatic  heart  dis- 
ease, 729 
tibrosis,  668,  671 

complications  of,  677 
diagnosis  of,  677 
emi)hysen)a  in,  677 
etiology  of,  672 

following  lobar  ])neumonia,  640 
histology  of,  (»73 
pali)ation  in,  675 
pathology  of,  673 
phy.sical  signs  of,  675 
prognosis  of,  678 
quiescent  period  of,  676 
symptomatology  of,  674 
treatment  of,  (579 
infarction   in  rheumatic  heart   disease, 

727 
stenosis,  690,  691.     See  also  Heart,  Dis- 
ease of,  683 
Purpura,  823 

cachectic,  828 
etiology  of,  828 
fulmiiians,  831 
giant  of  Werlhof,  832 
diagnosis  of,  832 
treatment  of,  832 
hemorrhagica,  828,  830 

diagnosis  of,  831 
Henoch's,  831 
in  infectious  disease,  828 
pathology  of,  829 
primary,  829 

rheumatic,  of  Schunlein,  832 
in  rheumatic  heart  disease,  730 
simplex  828 
symptomatology  of,  829 


INDEX. 


1009 


Pui-pui-a,  toxic,  829 

treatment  of,  833 
Pustular  eczema,  973.     See  Eczema,  969 
Pyelitis,  777 

primary,  777 

diagnosis  of,  779 
prognosis  of,  779 
treatment  of,  779 
secondary,  778 

symptomatology  of,  778 
treatment  of,  779 
Pylorus,    congenital    hypertrophy  of,   221. 
See  Congenital  Hijpertrophy  of  Pylo-rus,  221 


Q 


UADPJPLEGIA,  spastic,  957,  962 
Quincv.     See  Ab.<c€.is,  Grcumtonsillar, 
592' 


RACHITIS,  321 
anemia  in,  32-4 
blood  in,  323 
bones  in,  323,  325,  326 
compared  with  cretinism,  854 
dentition  in,  325 
diagnosis  of,  329 
diet  in,  322,  330 
etiology  of,  321 
heart  in,  324 
hygiene  in,  330 

laryngismus  stridulus,  due  to,  598 
liyer  in,  331 

mucous  membranes  in,  324,  328 
neryous  system  in,  328 
pathology  of,  323 
phosphorus  in,  331 
prognosis  of,  329 
pseudoparalysis  in,  329 
symptomatology  of,  324 
treatment  of,  329 
urine  in,  327 
Eectum,  polypus  of,  309 

pathology  of,  309 
symptomatology  of,  309 
treatment  of,  309 
prolapse  of,  307 

diagnosis  of,  301 
etiology  of,  308 
symptomatology  of,  308 
treatment  of,  308 
Reflex  conyulsions,  872 

prognosis  of,  873 
symptomatology  of,  872 
treatment  of,  873 
Eenal  calculus,  798 
colic,  798  _ 
decapsulation,  792 

infarction  in  rheumatic  heart  disease, 
727 
Eetromaxillary  lymph  nodes,  tuberculosis 
of,  351,  358".     See  Lymph  Node.--,  Tuber- 
culosis of,  344 
Eetroperitoneal  lymph  nodes,  tuberculosis 
of,  351.     See  Lymph  Nodes,  Tuberculosi.i 
of,  344 
Eetropharyngeal  abscess,  acute,  593.     See 
Abscess,  Eetrophnryngeal,  593  , 

64 


Eheumatic  pericarditis,  70 1 .     See  Pericardii 

list,  Pheuraatic,  701 
EheumatLsm,  574 

anemia  in,  577 

blood  in,  814 

chorea  in,  576 

chronic  fibrous,  581 

diagnosis  of,  582 
prognosis  of,  582 
treatment  of,  582 

diagnosis  of,  578 

from  rickets,  578 
from  scur\y,  578 

etiology  of,  574 

heart  lesions  caused  by,  576,  686,  695, 
701,  712,  716 

infectious  theory  of,  574 

joints  afl'ected  in,  575 

occurrence  of,  575 

pathology  of,  575 

pleurisy  in,  577 

pneumonia  in,  577 

skin  lesions  of,  576 

subcutaneous  nodules  in,  577 

symptomatology  of,  575 

tonsilitis  in,  576 
Eheumatoid   arthritis,    582.     See  Arthritis 

I)eforrno.n.<,  582 
Pickets,  321.     See  Puichitis,  321 
Root  palsies,  891 
Eotheln,  535.     See  Rubella,  535 
Rubella,  535 

contagiousness  of,  535 

clinical  types  of,  536 

desquamation  in,  537 

diagnosis  of,  537 

eruption  of,  537 

etiology  of,  5.35 

lymph  nodes  in,  537 

measles  type  of,  536 

period  of  contagiousness  of,  535 
of  incubation  of,  535 

prognosis  of,  538 

scarlatinal  type  of,  536 

symptomatology  of,  536 

treatment  of,  5.38 
Rubeola,  519.     See  Measles,  519 

SALIVA,  69 
Scabie:^,  988_ 

diagnosis  of,  989 
symptomatology  of,  988 
treatment  of,  990 
Sarcoma  of  spleen,  848 
Scales  for  infants,  166 
Scarlatina,  846.     See  Scarlet  Fever,  846 
Scarlet  feyer,  486 

adenitis  in,  496,  503 
angina  of,  501 
arthritis  in,  503 

bloofl  in,  505,  514 
cellulitis  in,  503 
clinical  types  of,  490 
complications     and     sequelte     of, 

501 
constitutional  symptoms  of,  501 


1010 


INDEX. 


Scarlet  fever,  (lesqiianiation  in,  498 

diaf^nosisof,  oOo 

empyema  in,  5U4 

eniloi-iinntis  in,  504 

erni>tion  of,  497 

eti(>l()j2;y  of,  486 

heart  tlisease  in,  504 

malifrnant  type  of,  492 

mild  type  of,  491 

nei)liritis  in,  504,  518 

nervous  symptoms  in,  505 

ordinary  type  of,  490 

other  exanthemata  with,  505 

otitis  in,  502 

l)athoiof?y  of,  489 

perii-arditis  in,  504 

period      of      contagiousness      of, 
489 
of  incubation  in,  488 

portal  of  entrance  of,  488 

pleurisy  in,  5(i4 

pleuropneumonia  in,  504 

pneumonia  in,  504 

predisposing  causes  of,  487 

prognosis  of,  507 

prophylaxis  in,  508 

pulse  in,  495 

recurrence  and  relapse  in,  507 

severe  type  of,  491 

sick-room  for,  51 1 

sources  of  infection  in,  488 

surgical,  492 

sym[)tomatology  of,  493 

temperature  in,  494 

throat  in,  495 

tongue  in,  500 

urine  in,  500 

treatment  of,  514 
Sclerosis  disseminatecl,  912 

diagnosis  of,  913 

etiology  of,  912 

pathology  of,  912 

prognosis  of,  914 

symptomatology  of,  912 

treatment  of,  914 
multi|)le,  912.     See  Sderosis,  Dissemin- 
nted,  912 
Scorbutus,  332 
blood  in,  335 
diagnosis  of,  329,  335 

from  rheumatism,  578 
diet  in,  336 
etiology  of,  332 
gums  in,  334 

hemorrhage  in,  333,  334,  335 
pain  in,  334 
pathology  of,  333 
prognosis  in,  335 
proj)rietary  foods  in,  333 
{)seudoj)aralysisin,  334,  335 
sym])tomatology  of,  334 
treatment  of,  336 
Scrofula,  350 

inguinal,  351 
mediastinal,  351,  358 
Scurvy,  332.     See  Scorbutus,  332 


Serofibrinous  pleurisy,  646.  See  Pleurisy,  646 
Serosities,  nniltiple,  725 
diagnosis  of,  72(5 
prognosis  of,  726 
treatment  of,  726 
Shiga  bacillus  in  gastroenteric  infections, 

227 
Skin  disea.ses,  969 

syphilis  of,  565,  567 
Smallpox,  552 

clinical  tyjjcs  of,  554 

complications  and  secjuehe  of,  557 

constitutional  symptoms  of,  557 

diagnosis  of,  544,  558 

erujition  of,  555 

etiology  of,  552 

eyes  in,  557,  561 

fever  in,  555 

hemorrhagic  type  of,  554 

nnxlified  (varioloid)  form  of,  555 

oi'dinary  type  of,  554 

otitis  in,  557 

pei'iod  of  contagiousness  in,  554 

of  incubation  in,  553 
predisposing  causes  of,  553 
jirognosis  of,  558 
prophylaxis  in,  559 
relapse  and  recurrence  of,  557 
sources  of  infection  in,  553 
treatment  of,  559 
Spasmodic  croup,  595.  See  Laryngitis  Stridvr 

lorn,  595 
Spastic  hemiplegia,  957 
aphasia  in,  961 
diagnosis  of,  963 
epilepsy  in,  961 
etiology  of,  957 
mental  defects  in,  961 
pathology  of,  959 
j)rognosis  of,  963 
symptomatology  of,  959 
treatment  of,  963 
j>aralysis,  hereditary,  916 
paraplegia,  957,  962 
quadriplegia,  957,  962 
Spina  bifida,  926 

diagnosis  of,  928 
etiology  of.  926 
pathology  of,  926 
pi'ognosis  of,  928 
symptomatology  of,  927 
treatment  of,  928 
Spinal  column,  growth  of,  66 
cord,  concussion  of,  908 

prognosis  of,  908 
treatment  of,  908 
disease  of,  891 
hemorrhage  of,  908 
prognt)sis  of,  909 
symptomatology  of,  909 
treatment  of,  909 
malformations  of,  926 
syphilitic  disease  of,  910 
diagnosis  of,  911 
symptomatology  of,  911 
treatment  of,  912 


INDEX. 


1011 


Spinal  cord,  tumors  of,  905 

diagnosis  of,  906 
prognosis  of,  907 
symptomatology  of,  906 
treatment  of,  907 
Spine,  fracture  or  dislocation  of,  910 

treatment  of,  910 
Spleen,  amyloid,  846 
carcinoma  of,  848 
chronic  passive  congestion  of,  846 
cystic  tumors  of,  848 
disease  of,  844 
enlargement  of,  846 
in  rickets,  846 
in  tuberculosis,  846 
floating,  847 
new  growths  in,  848 
parasites  in,  848 
sarcoma  of,  848 
tuberculosis  of,  848 
Splenic  infarction  in  rheumatic  heart  dis- 
ease, 727 
Splenitis  and  perisplenitis,  847 
Splenomegaly,  primary,  847 
Splenomyelogenous    leukemia,    824.      See 

Leukemid,  824 
Spondylitis  deformans.  583 
treatment  of,  583 
Status  lymphaticus,  837 
thymicus,  837 

etiology  of,  838 
pathology  of,  838 
symptomatology  of,  838 
ti-eatment  of,  839 
Still's  chronic  joint  disease,  584 

prognosis  of,  584 
symptomatology   of,   584 
treatment  of,  584 
Stomach,  dilatation  of,  219 
pathology  of,  220 
symptomatology  of,  220 
diseases  of,  196 

hypertrophic    stenosis    of,    221.      See 
Congenital   Hypertrophy  of     Pylorua, 
221 
in  infancy  and  childhood,  196 
Stomatitis,  aphthous,  177 
diagnosis  of,  178 
etiology  of,  177 
lesion  of,  178 
symptomatology  of,  178 
treatment  of,  178 
catarrhal,  diagnosis  of,  176 
lesion  of,  175 
symptomatology  of,  176 
treatment  of,  176 
diphtheritic,  186,  399 
treatment  of,  186 
gangrenous,  187,  531 
etiology  of,  187 
lesions  of,  188 
pathology  of,  187 
prognosis  in,  191 
symptomatology  of,  189 
treatment  of,  191 
gonorrheal,  185 


Stomatitis,   herpetic,   177.      See  Stomatitis, 
Aphthous,  177 
mycotic,  diagnosis  of,  183 
lesions  of,  182 
prognosis  in,  183 
symptomatology  of,  182 
treatment  of,  183 
syphilitic,  185 

diagnosis  of,  186 
treatment  of,  186 
ulcerative,  179 

diagnosis  of,  180 
noma  in,  180 
pathology  of,  179 
symptomatology  of,  179 
treatment  of,  180 
Stools,  bloody,  154 
disturbed,  152 
fatty,  153 
first,  151 
green,  153 
mucous,  153 
normal,  152 
watery 
St.  Vitus  dance,  863.     See  Chorea,  863 
Syringomyelocele,  927 
Subdural  hemorrhage,  954 
diagnosis  of,  955 
treatment  of,  955 
Suppurative   pericarditis,    764.     See    Peri- 
carditis, Suppurative,  764 
Suprarenal  glands,  849.     See  Adrenals,  849 
Syphilis,  acquired,  563 
bones  in,  565,  569 
congenital,  55,  60,  329,  335,  310,  463, 

563 
diagnosis  of,  571 
etiology  of,  563 
eyes  in,  571 
gummata  in,  570 
heart  disease  in,  755 
hereditary,  563 
liver  in,  564,  570 
nasal  catarrh  in,  567,  587 
of  newborn,  55,  60 
otitis  in,  571 
pathology  of,  564 
prognosis  of,  572 
skin  in,  565,  567 
of  spinal  cord,  910 

diagnosis  of,  911 
symptomatology  of,  911 
treatment  of,  912 
symptomntology  of,  565 
teeth  in,  571 
treatment  of,  55,  58,  573 
Syphilitic  stomatitis,   185.     See   Stomatitis, 
Syphilitic,  185 

TEETH,  growth  of,  67 
permanent,  68 
syphilitic,  571 
temporaiy,  671 
Tenia  saginata,  311.     See  Wo7-ms,  Intestinal, 
310 
solium,  312.     See  Worms,  Intestinal,  310 


1012 


INDEX. 


Tetanus  neonatorum,  57 
treatment  of,  58 
Thomsen's  disease,  882 

liatli()lof,'y  of,  882 
syniptoniatoldyy  of,  882 
Thrombosis  of  eerehral  sinus,  938 
tliafi;nosis  of,  It.Si) 
patliolojijy  of,  lto8 
j)r(\i;ii(isis  of,  '.HO 
syiuptoniatolo^y  of,  \V.V^ 
t'reatiiient  of,  \)\() 
of  veins  in  rheuiuatie  heart  disease,  727 
Thymic  asllinia,  8.")7 

diagnosis  of,  So7 
treatment  of,  8o7 
Thymus  gland,  83G 

heart  disease  with  enlarged,  688 
hypertro])hy  of,  837 
sudden  death  with  enlarged,  837 
Tonsil,  abscess  around,    592.     See  Abaccsi^, 
Circumlonsilhir,  592 
hypertrophy  of,  ehronie,  592 
treatment  of,  592 
Tonsilitis,  follicular,  591 
diagnosis  of,  592 
and  rheumatism,  57G 
symptomatology  of,  591 
treatment  of,  592 
Toxic  jiurpura,  829.     See  Purpura,  823 
Trachea,    diphtheria   of,    397.     See    JJiph- 

therui,  385 
Tracheobronchitis,  604 
Tricuspid  stenosis  ;ind   regurgitatiou,  713. 
See  also  Heart, Diseai^e  of,  683 
diagnosis  of,  714 
Tuberculosis,  339,  343 

age  of  occurrence  of,  348 
bacillus  of,  343 
climate  for,  368 
eytodiagnosis  of,  349 
diagnosis  of,  348 

pulmonary     from     bronchopneu- 
monia, 627 
empyema  with,  658 
etiology  of,  345 
heart  in,  753 
hereditary  in,  345 
infection  by,  346 
of  intestine,  370 

diagnosis  of,  372 
pathology  of,  370 
prognosis  of,  373 
symptomatology  of,  372 
treatment  of,  373 
of  kidney,  804 

diagnosis  of,  804 
pathology  of,  804 
prognosis  of,  804 
symptomatology  of,  804 
treatment  of,  804 
localization  of,  314 
lungs  in,  344,  363,  364,  365,  366 
of  lymph  nodes, 

bronchial,  351,  354,  355,  356, 

357 
cervical,  351,  353 


Tuberculosis  of    lymph   nodes,    epigastric, 
351 
mesenteric,  351 
portal,  351 

retromaxillary,  351,  358 
retroperitoneal,  351 
miliary,  359 

diagnosis  of,  363 
etiology  of,  360 
mariuitic  forui  of,  361 
pathology  of,  359 
pneumonic  form  of,  362 
symptoms  of,  360 
typhoid  form  of,  362 
milk  I'ausing,  34(),  369 
jieritoneum  in,  369,  370 
projihylaxis  of,  366 
serum  in,  349 
of  spleen,  848 
symptomatology  of,  353 
trcatiiK'nt  of,  366,  368 
tuhercMlin  in,  349 
Tuberculous  bronchopneumonia,  363.     See 
Jironchopiieumonia,  Tuberculous,  363 
meningitis,  379.    See  MenDujitix,  Tuber- 
culosis, 379 
peritonitis,  373 

retropharyngeal  abscess,  594.     See  Ab- 
scess, lieiropharynyeal,  594 
Tumors  of  brain,  944 

pathology  of,  945 
symptomatology  of,  946 
convulsions  as,  947 
headache  as,  946 
localization  of, 
optic  neuritis  as,  947 
vomiting  as,  947 
of  cerebellum,  950 
diagnosis  of,  950 
prognosis  of,  952 
treatment  of,  952 
surgical,  952 
of  kidney,  800 
of  spinal  cord,  905 

diagnosis  of,  906 
pi-ognosis  of,  907 
symptomatology  of,  906 
treatment  of,  907 
of  spleen,  cystic,  848 
Typhoid  fever,  427 

abdominal  symptoms  in,  436 

aphasia  in,  441 

arthi-itis  in,  442 

blood  in,  439 

bone  and  joint  affections  in,  442 

conjunctivitis  in,  441 

diagnosis  of,  443 

laboratory,  444 
diazo  reaction  in,  438 
tlur.ition  of,  443 
ear  in,  441 
etiology  of,  427 
fetal,  431 
fever  in,  434 

frequency  in  children  of,  428 
gastroenteric  tract  in,  435. 


INDEX. 


1013 


Typhoid  fever,  general  management  of,  449 
diet  in,  449 

heart  in,  431 

heart  weakness  in,  453 

hemorrhage  in,  436 

hemorrhagic  form  of,  442 

hemiplegia  in,  44u 

herpes  labialis  in,  436 

hypothermia  in,  434 

infantile,  431 

kidney,  lesions  in,  438 

lymph  nodes  in,  440 

mental  affections  eomplicating,441 

mesenteric  lymph  nodes  in,  430 

mild  type  of,  432 

mouth  in,  435 

mucous  membranes  in,  430 

nervous  symptoms  in,  440 

occurrence      with      exanthemata, 
443 

organs  of  special  sense  in,  441 

pain  in,  437 

paratyphoid  fever,  diagnosis  from, 
44o 

parotitis  in,  442 

pathology  of,  429 

perforation  in,  436 

predisposing  factors  in,  428 

prognosis  of,  448 

pulse  in,  435 

pyemia  in,  447 

respiratory  organs  in,  437 

rose  spots  in,  439,  444 

seasons  of,  428 

serous  membrane  in,  430 

severe  type  of,  432 

skin  in,  439 

spleen  in,  430,  435,  443 

stools  in,  436 

symptomatology  of,  433 

tongue  in,  435 

treatment  of,  448,  451 
alcohol  in,  450 
of  hemorrhage  in,  452 
hydrotherapy  in,  450 
special,  448 

tuberculosis,  diagnosis  from,  446 

urine  of,  438 

visceral  changes  in,  439 

vomiting  in,  451 

ULCERATIVE   appendicitis,    294.     See 
Appendicitis,  294 

ileocolitis,  252.    See  Ileocolitis,  252 
stomatitis,  179 

diagnosis  of,  180 
noma  hi,  180 
pathology  of,  179 
symptomatology  of,  179 
treatment  of,  180 
Umbilical  cord,  38 

accidents  to,  38 
fungus  of,  40 
hemorrhage  of,  39 

treatment  of,  39 
infection  of,  40 


Umbilical  infection ,  treatment  of,  40 
Unicinaris   duodenalis,    319.     See    Worms, 

Intestinal,  310 
Urethritis  in  the  male,  761 
gonorrheal,  701 
simple,  761 

treatment  of,  761 
symptomatology  of,  762 
treatment  of,  762 
Uric  acid  infarcts,  798 
Urinary  calculi,  797 
Urine,  769 

albumin  in,  773 
blood  in,  776 
of  newborn,  19 
suppression  of,  771 
Urticaria,  983 

diagnosis  of,  984 
etiology  of,  984 
papular,  984 
treatment  of,  984 
Uvula,  affection  of,  193,  194 

T7ACCINIA,  545 
V      clinical  history  of,  546 
complications  of,  549 
constitutional  symptoms  from,  547 
eruption  of,  546 
history  of,  545 
incubation  of,  546 
irregular,  548 
protective  power  of,  545 
repetition  of,  551 
selection  of  lymph  for,  551 
technique  of,  550 
time  for,  551 

transmission  of  disease  by,  549 
Vaccination,  545,  559.     See  Vaccinia,  bio 
Valvular  lesions  of  heart,  multiple,  715.  See 
also  Heart  Disease,  683 
diagnosis  of,  715 
Varicella,  541 

clinical  history  of,  541 

complications  of,  543 

diagnosis  of,  544 

eruption  of,  542 

erysipelas  in,  544 

etiology  of,  541 

gangrenous  dermatitis  in,  543 

period  of  contagiousness  of,  541 

of  incubation  in,  541 
prognosis  of,  544 
symptomatology  of,  542 
temperature  in,  542 
treatment  of,  544 
Varioloid,  555.     See  Smallpox,  552 
Veins,    thrombosis  of,   in   rlieumatic  heart 

disease,  727 
Vesical  calculus,  799 

diagnosis  of,  799 
prognosis  of,  799 
treatment  of,  799 
spasm,  766 

etiology  of,  766 
symptomatology  of,  766 
treatment  of,  767 


1014 


INDEX. 


Vesicular  eczema,  973,     See  Eczema,  969 
Voniitinjif,  acute,  149 
liabitiuti,  l.")() 
iccunviit,  199 

acetone  tests  for,  ?.(}l 

diaj^nosis  of,  201 

etiology  of,  199 

Legai's  test  in,  201 

Lichen's  test  in,  201 

prognosis  of,  202 

Keynoki's  test  in,  201 

syiiiittoinatoiogy  of,  200 

treatment  of,  202 
Vulvovaginitis,  702 
gonorrheal,  703 

diagnosis  of,  7C5 

prognosis  of,  705 

syMi|>toniatoIogy  of,  7G4 

treatment  of,  7(iO 
simple  cMtarrlial,  702 

patliology  of,  703 

symptomatology  of,  703 

treatment  of,  705 

WASSERKREBS,  187.     See   Stomnliti^, 
GanrjrenouH,  187 
AVeaning,  105 

Weighing  and  choice  of  scales,  166 
"Weight  cliart,  100 
AVhey  and  cream  mixtures,  100 

mixtures,  100 
Whooping-cough,    472 

age  atlected  by  472 

bIo(Kl  in,  814 

bronchitis  in,  472 

bronchopneumonia  in,  625 

complications  and  setpielic  of,  57  5 


Whooping  cough,  contagion  of,  473 
convulsions  in,  475 
diagnosis  of,  470 
emi)hysema  in,  475 
hemorrhages  in,  475 
mode  of  infection  of,  472 
mortality  from,  477 
occurrence  of,  472 
otitis  in,  470 
pathology  of,  453 
l)eri(xi  of  decline  of,  474, 
prognosis  of,  471 
symptomatology  of,  473 
treatment  of,  478 

of  complications,  479 

local,  478 
tuberi'ulosis  following,  476 
Worms,  hook,  319 

diagnosis  of,  319 

prognosis  of,  319 

symptomatology  of,  319 

treatment  of,  3i9 
intestinal,  310 

diagnosis  in,  315 

symptomatologv  of,  315 

tiipe,  311 

tenia  saginata,  311 
solium,  312 

treatment  of,  315 
rf)und,  310 

diagnosis  of,  317 

symi)tomatol()gy  of,  .'51G 

treatment  of,  317 
thread,  317 

diagnosis,  of,  318 

symptomatology  of,  317 

treatment  of,  318 


